Exposure Posttraumatic Stress Disorder Research Articles

Perceptions and experiences of web-prolonged exposure for posttraumatic stress disorder: A mixed-methods study.

Web-based prolonged exposure therapy (Web-PE) has potential to increase the reach of effective posttraumatic stress disorder (PTSD) treatment. While there is initial support for the efficacy of Web-PE, no studies have examined the perceptions and experiences of participants receiving PE in this novel, Web based format. We used a mixed-methods convergent design to examine and integrate quantitative and qualitative data of participant perceptions and experiences of Web-PE. Treatment-seeking active duty military personnel or veterans (N = 29) who received Web-PE completed posttreatment surveys about perceptions of Web-PE and a brief qualitative interview. Thematic coding was used to identify qualitative themes, which were integrated with quantitative data in a joint display. Although many were initially skeptical of experiencing benefit, participants reported that Web-PE was helpful. They appreciated the flexibility of online therapy and reported that self-motivation was important for engagement. Web-PE therapists were well-regarded, although additional therapist support and technical improvements to the Web-PE program were suggested. Scores on the perceptions of Web-PE survey, PTSD survey, and other quantitative data corroborated the qualitative themes. Perceptions and experience of Web-PE are favorable and help to highlight the strengths (e.g., flexibility) and challenges (e.g., requiring self-motivation) associated with Web-treatment for PTSD. The results of this study may inform further development of Web-PE or other Web-based treatment programs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Within-patient association between emotion regulation and outcome in prolonged exposure for posttraumatic stress disorder.

Difficulties with emotion regulation (ER) are a risk factor for the development and maintenance of posttraumatic stress disorder (PTSD). Less is known about temporal relations between ER and PTSD symptom change during treatment, including whether ER may represent a more potent change ingredient for some patients relative to others. This study examined the association between within-patient changes in ER and next-session PTSD symptom change and whether this association was more pronounced for patients with poorer baseline ER, more severe depression, or higher borderline personality disorder symptoms. Data derived from a randomized controlled trial (NCT01600456) in which 149 adults with PTSD received up to 10 sessions of prolonged exposure (PE) or PE + sertraline. Patients rated difficulties with ER and PTSD symptoms repeatedly during treatment. Moderators were assessed at baseline. Cross-lagged, dynamic structural equation models revealed that ER improvements were associated with next-session reductions in PTSD (standardized effect = 0.13). PTSD symptom reduction was also associated with next-session ER improvement (standardized effect = 0.34). Moderator analyses revealed that the within-person ER-PTSD symptoms association was stronger for patients with higher baseline depression (standardized effect = 0.39). Reductions in PTSD symptoms may facilitate ER improvements during PE and PE augmented with sertraline rather than improvements in ER producing changes in PTSD symptoms. For patients with higher severity co-occurring depression, ER may represent a more active change ingredient. PE therapists could therefore consider placing particular emphasis on improving ER capabilities when working with this subgroup of patients. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Supplemental Material for Within-Patient Association Between Emotion Regulation and Outcome in Prolonged Exposure for Posttraumatic Stress Disorder

Supplemental Material for Within-Patient Association Between Emotion Regulation and Outcome in Prolonged Exposure for Posttraumatic Stress Disorder

Individual symptom reduction and post-treatment severity: Varying levels of symptom amelioration in response to prolonged exposure for post-traumatic stress disorder.

Many patients evince significant post-traumatic stress disorder (PTSD) symptoms after a dose of an evidence-based treatment (EBT) for PTSD. Little research systematically addresses if individual PTSD symptoms are more or less resistant to change through an EBT for PTSD or have greater or lesser post-treatment severity levels. Two studies within VA medical centers provided data. Study 1 (n = 81) was drawn from a randomized clinical trial of Prolonged Exposure (PE), an EBT for PTSD. Study 2 (n = 225) was drawn from two PTSD specialty clinics employing PE. Symptoms were assessed pre- and post-treatments via semi-structured clinician interview (Study 1) and patient self-report (Studies 1 and 2). Most individual symptoms reduced about the same amount through the course of treatment except for avoidance, which showed greater reductions. High heterogeneity in post-treatment symptom severity was found with troubled sleep and hypervigilance displaying above average levels, and traumatic amnesia, foreshortened future, and flashbacks displaying below average levels. Method of symptom measurement had a modest impact on results, as semi-structured clinical interview results were moderately more differentiated than self-report measures. Results were generally consistent between an efficacy (i.e., extremely high, potentially artificial methodological control) and effectiveness (i.e., relatively more real world) context. Primary limitation is analysis of single items on semi-structured clinician interview and patient self-report scale when psychometric validation studies did not interpret measures this way. Moreover, DSM-IV criteria for PTSD were assessed. EBT augmentation and new treatment development should focus on further reducing both PTSD symptoms in general and on the specific symptoms of troubled sleep and hypervigilance, which persist to a greater degree. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Clinical Effectiveness of an Intensive Outpatient Program for Integrated Treatment of Comorbid Substance Abuse and Mental Health Disorders

Comorbid substance use disorders (SUDs) and mental health disorders are a pervasive problem among post-9/11 veterans and service members. Treatment of SUD and comorbid disorders has historically occurred separately and sequentially, and when treated concurrently has been primarily done in a weekly outpatient setting, which has high rates of dropout. The current study describes an integrated 2-week intensive outpatient treatment (IOP) using cognitive-behavioral therapy, including prolonged exposure for posttraumatic stress disorder (PTSD), unified protocol for anxiety and mood disorders, and relapse prevention for SUD. Forty-two patients completed the comorbid treatment program. Results indicated that self-reported substance use, PTSD, and depression symptoms significantly decreased following treatment, while satisfaction with participation in social roles increased. These preliminary effectiveness data indicate that comorbid SUD and mental health disorders can be effectively treated in a 2-week intensive outpatient program.

A Case Study of Prolonged Exposure for Posttraumatic Stress Disorder With a Latino Male with Polysubstance Use, Severe Depression, and Anger in a Residential Substance Use Treatment Program

Substance use disorders and post-traumatic stress disorder (PTSD) often co-occur, along with depression and anger. Despite evidence that Prolonged Exposure Therapy is effective for individuals with co-occurring PTSD and SUD when PE is implemented alongside SUD treatment, clinicians have been reluctant to offer PE or other trauma-focused therapies to individuals with co-occurring PTSD and SUD because of the belief that increased emotional distress would be counter-therapeutic for individuals in early recovery. A widely held explanation for the high degree of comorbidity is that individuals with PTSD use substances to reduce or avoid painful and disturbing PTSD symptoms. This case study describes the implementation and outcome of PE therapy with a 32-year-old man who had been admitted to a residential substance use treatment program for Latino males. The client had a long history of polysubstance use and severe PTSD. The client was homeless and reported significant depressive and anger symptoms. Assessment of PTSD revealed that he was using heroin and cocaine to avoid painful memories of a traumatic event that had occurred several years prior to his admission to this treatment program. Because the client reported using these substances to reduce emotional distress, PE was chosen as the PTSD intervention. During PE Therapy the client reported no thoughts or urges to use substances and at discharge from residential treatment he reported no problems with PTSD or depression. The client maintained all gains at 1-year follow-up, when he also reported that he was working full time and had remained abstinent since he completed treatment.

Sleep disorder symptoms and massed delivery of prolonged exposure for posttraumatic stress disorder: Nodding off but not missing out.

The impact of disrupted sleep on the effectiveness of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) is not well understood. Researchers have suggested that comorbid sleep disorders contribute to nonresponse by impairing therapeutic mechanisms such as emotional processing of trauma memories and extinction in cued fear conditioning. Several studies indicate daytime sleepiness, insomnia, and nightmares are correlated with PTSD symptom severity. However, a recent randomized controlled trial found that these sleep disorder symptoms did not affect PTSD symptom change over the course of massed PE (i.e., daily sessions across 2 weeks). The current study used an ecologically valid clinical sample to examine whether daytime sleepiness, insomnia, and nightmares interfere with the slope of symptom change in massed PE. Results indicate that all 3 sleep disorder symptoms correlate with PTSD symptom severity on the first day of treatment but were not associated with symptom change. These findings are consistent with the expectation that the daily structure of massed PE may enhance treatment engagement in patients who are typically drowsy or not well-rested, thus facilitating fear extinction. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Massed versus standard prolonged exposure for posttraumatic stress disorder in Australian military and veteran populations (RESTORE trial): Study protocol for a non-inferiority randomized controlled trial

Posttraumatic stress disorder (PTSD) can be a severe problem, affecting veterans and military personnel at higher rates than the general community. First-line treatment for PTSD, prolonged exposure (PE), is typically delivered weekly for 10–12 weeks, however this duration can pose a barrier to accessing and completing the treatment, particularly for current serving military. This paper presents the RESTORE trial protocol, the first randomized controlled trial of massed PE therapy outside of the United States and by an independent research group. One hundred and thirty-five Australian Defence Force members and veterans (18–80 years) who meet criteria for PTSD related to a military trauma will be randomly allocated to one of two conditions: standard PE (SPE; 10 weekly 90-min sessions) or massed PE (MPE; 10 daily 90-min sessions). Across eight sites, patients will be assessed at pre-treatment, and at 4 weeks, 12 weeks, and 12 months post-treatment commencement. The primary outcome is clinician-measured and self-reported PTSD symptom severity at the 12 week assessment. We hypothesize that MPE will be as effective as SPE in reducing PTSD severity at 12 weeks post-treatment commencement. The adaptation and testing of evidence-based interventions is critical to reduce barriers to treatment uptake among veterans and military personnel. Outcomes of this study have the potential to result in international, cross-service uptake and delivery of this rapid treatment for veterans and military members, as well as civilians, thereby improving clinical outcomes for patients and their families.

Psychophysiology during exposure to trauma memories: Comparative effects of virtual reality and imaginal exposure for posttraumatic stress disorder.

This investigation involved an in-depth examination of psychophysiological responses during exposure to the trauma memory across 10 sessions among active duty soldiers with combat-related posttraumatic stress disorder (PTSD) treated by Prolonged Exposure (PE) or Virtual Reality Exposure (VRE). We compared psychophysiological changes, session-by-session, between VRE and traditional imaginal exposure. Heart rate (HR), galvanic skin response (GSR), and peripheral skin temperature were collected every 5 min during exposure sessions with 61 combat veterans of Iraq/Afghanistan and compared to the PTSD Checklist (PCL-C) and Clinician-Administered PTSD Scale (CAPS) outcomes using multilevel modeling. Over the course of treatment, participants in the PE group had higher HR arousal compared to participants in the VRE group. With reference to GSR, in earlier sessions, participants demonstrated a within-session increase, whereas, in later sessions, participants showed a within-session habituation response. A significant interaction was found for GSR and treatment assignment for within-session change, within-person effect, predicting CAPS (d = 0.70) and PCL-C (d = 0.66) outcomes. Overall, these findings suggest that exposure to traumatic memories activates arousal across sessions, with GSR being most associated with reductions in PTSD symptoms for participants in the PE group.

Emotional Processing of Imaginal Exposures Predicts Symptom Improvement: Therapist Ratings Can Assess Trajectory in Prolonged Exposure for Posttraumatic Stress Disorder.

Research on mechanisms of change in prolonged exposure therapy (PE), an evidence-based treatment for posttraumatic stress disorder (PTSD), is ongoing. Two putative mechanisms of change are engagement during imaginal exposure and trauma-related belief change. The PE Therapist Questionnaire (PETQ), a novel measure based on the emotional processing theory underlying PE, was developed as a practical tool for therapists to use to assess (a) patient engagement during imaginal exposures and (b) perspective shifts during postimaginal processing. Patients (N = 151) at a U.S. Veterans Affairs medical center PTSD specialty clinic completed self-report measures of PTSD and depression symptoms prior to sessions. Study therapists (n = 17) completed the PETQ postsession. Rational construction and psychometric analyses suggested a two-component solution for the PETQ: imaginal and processing. The imaginal factor did not relate to PTSD and depression symptoms. The processing factor correlated with current and next-session PTSD and depression symptoms, with medium effect sizes, rs = -.41 to -.45, ps < .001. Controlling for current-session PTSD and depression, a higher level of processing predicted lower next-session PTSD severity, with a small effect size, β = -.38, p < .04.Postexposure emotional processing, which supports positive changes in maladaptive trauma-related beliefs and tolerance of emotional distress, predicted future symptom improvement, highlighting the importance of processing components in PE. Further, the use of therapist observations may offer ancillary methods less influenced by correlation of within-patient subjective ratings and concomitant risk of construct overlap in mechanisms research.

The efficacy of 90-minute versus 60-minute sessions of prolonged exposure for posttraumatic stress disorder: Design of a randomized controlled trial in active duty military personnel.

Posttraumatic stress disorder (PTSD) can have devastating effects on multiple aspects of functioning. Thus, it is imperative to increase access to evidence-based treatment for PTSD. Prolonged Exposure therapy (PE) has extensive empirical support and is one of the first-line PTSD treatments included in civilian, veteran, and military clinical practice guidelines. However, the standard 90-min PE session format can constitute a significant barrier to its adoption in routine clinical care settings, which typically schedule 60-min appointment sessions. If the length of PE sessions could be reduced from 90 to 60 min without compromising treatment efficacy and efficiency, this would remove a major barrier to PE adoption. This paper describes the rationale and methods of a randomized controlled noninferiority trial comparing 90-min versus 60-min PE sessions (including 40- vs. 20-min imaginal exposures, respectively) among 160 active duty military personnel with PTSD. The aims of this study are to: (1) examine the efficacy and efficiency (i.e., rate of symptom improvement) of 90- versus 60-min PE; (2) assess change in psychophysiological markers of treatment response across conditions; and (3) test mechanisms of change underlying the efficacy of PE. The results of this study will inform dissemination efforts in military, veteran, and civilian sectors. Further, identifying mechanisms of therapeutic change will answer important theoretical questions about how PE works, in order to refine and increase the efficacy and efficiency of PE to better meet the needs of individuals with PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Combined transcranial direct current stimulation with virtual reality exposure for posttraumatic stress disorder: Feasibility and pilot results

BackgroundFacilitating neural activity using non-invasive brain stimulation may improve extinction-based treatments for posttraumatic stress disorder (PTSD). Objective/hypothesisHere, we examined the feasibility of simultaneous transcranial direct current stimulation (tDCS) application during virtual reality (VR) to reduce psychophysiological arousal and symptoms in Veterans with PTSD. MethodsTwelve Veterans with PTSD received six combat-related VR exposure sessions during sham-controlled tDCS targeting ventromedial prefrontal cortex. Primary outcome measures were changes in skin conductance-based arousal and self-reported PTSD symptom severity. ResultstDCS + VR components were combined without technical difficulty. We observed a significant interaction between reduction in arousal across sessions and tDCS group (p = .03), indicating that the decrease in physiological arousal was greater in the tDCS + VR versus sham group. We additionally observed a clinically meaningful reduction in PTSD symptom severity. ConclusionsThis study demonstrates feasibility of applying tDCS during VR. Preliminary data suggest a reduction in psychophysiological arousal and PTSD symptomatology, supporting future studies.

The American Telemedicine Association ATA 2017 Telehealth 2.0 Conference Abstracts.

The American Telemedicine Association ATA 2017 Telehealth 2.0 Conference Abstracts.

Repeated trauma exposure does not impair distress reduction during imaginal exposure for posttraumatic stress disorder.

Based on experimental research on threat extinction, individuals exposed to repeated traumatic events may have impaired outcome in exposure therapy compared to those who have experienced a single trauma (Lang & McTeague, ). This study examined whether repeated trauma exposure predicts smaller changes in self-reported distress during imaginal exposure and worse outcomes for patients with posttraumatic stress disorder (PTSD). Adults (N = 116) with chronic PTSD received up to 10 sessions of prolonged exposure (PE) therapy. Trauma exposure was assessed via interview and number of traumatic events were summed for each participant. To examine reductions in distress during treatment, mean and peak values of distress during imaginal exposure were calculated for the first imaginal session (initial distress activation) and subsequent sessions (between-session change in distress). Change in PTSD symptoms from pre- to posttreatment and follow-up provided an additional index of outcome. In-session distress during imaginal exposure decreased over the course of treatment. PTSD symptoms also decreased over treatment, with gains being maintained through follow-up. Repeated trauma exposure was not significantly correlated with initial distress activation. Additionally, linear mixed-model analyses showed no significant association between repeated trauma exposure and between-session change in distress or PTSD symptoms. Contrary to recent speculation, repeated trauma exposure did not predict less change in self-reported distress during imaginal exposure or worse PTSD outcomes. The bench-to-bedside linkage of threat extinction to exposure therapy is discussed, noting strengths and weaknesses. Patients with repeated trauma exposure show reductions in distress with exposure treatment and benefit from PE as much as patients with single-exposure trauma histories.

A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth

This is the first randomized controlled trial to evaluate non-inferiority of Prolonged Exposure (PE) delivered via home-based telehealth (HBT) compared to standard in-person (IP) PE. One-hundred thirty two Veterans recruited from a Southeastern Veterans Affairs Medical Center and affiliated University who met criteria for posttraumatic stress disorder (PTSD) were randomized to receive PE via HBT or PE via IP. Results indicated that PE-HBT was non-inferior to PE-IP in terms of reducing PTSD scores at post-treatment, 3 and 6 month follow-up. However, non-inferiority hypotheses for depression were only supported at 6 month follow-up. HBT has great potential to reduce patient burden associated with receiving treatment in terms of travel time, travel cost, lost work, and stigma without sacrificing efficacy. These findings indicate that telehealth treatment delivered directly into patients' homes may dramatically increase the reach of this evidence-based therapy for PTSD without diminishing effectiveness.

Emotional Activation and Habituation During Imaginal Exposure for PTSD Among Women With Borderline Personality Disorder.

The current study examined patterns and outcomes of emotional activation and habituation during imaginal exposure for posttraumatic stress disorder (PTSD). Participants were 16 women with borderline personality disorder (BPD), PTSD, and recent suicidal and/or self-injurious behavior who received imaginal exposure for PTSD concurrently with dialectical behavior therapy. The intensity of global distress and 6 specific emotions were assessed before and after imaginal exposure trials. Results indicated that significant within-session habituation (WSH) occurred for global distress (Hedge's g effect size = -2.52) and fear (g = -0.80), whereas significant between-session habituation (BSH) occurred for global distress (g = -2.18), fear (g = -1.89), guilt (g = -1.14), shame (g = -0.74), and disgust (g = -0.41). BSH significantly predicted PTSD diagnostic status at posttreatment, whereas activation and WSH were unrelated to outcome. Clients who remitted from PTSD showed significantly more BSH in global distress than nonremitters (η(2) = .39). In addition, remitters reported reductions in sadness and anger across trials, whereas sadness and anger increased for those who did not remit (η(2) = .54 and .40, respectively). Overall, BPD clients exhibited patterns of activation and habituation during imaginal exposure comparable to other client populations, and there was no evidence of persistent emotional engagement or habituation problems.

Patterns of therapeutic alliance: Rupture–repair episodes in prolonged exposure for posttraumatic stress disorder.

Patterns of therapeutic alliance: Rupture–repair episodes in prolonged exposure for posttraumatic stress disorder.

Patterns of therapeutic alliance: rupture-repair episodes in prolonged exposure for posttraumatic stress disorder.

To better understand the role of therapeutic alliance in posttraumatic stress disorder (PTSD) treatment, we examined patterns of and shifts in alliance. First, we identified individuals with repaired ruptures, unrepaired ruptures, and no ruptures in alliance. Then, we explored group differences in these alliance events for clients with common clinical correlates (i.e., co-occurring depression and childhood abuse history) and whether or not the presence of these events influenced treatment outcome. At pretreatment, clients (N = 116)-76.1% female, 66% Caucasian, age M = 36.7 years (SD = 11.3)--completed measures assessing PTSD diagnosis and severity (PTSD Symptom Scale Interview and Self-Report), depression diagnosis and severity (Structured Clinical Interview for DSM-IV and Beck Depression Inventory), and trauma history. During 10 weeks of prolonged exposure therapy, alliance (California Psychotherapy Alliance Scale) measures were completed. At posttreatment, PTSD and depression were reassessed. Ruptures in alliance were quite common (46%). No significant differences emerged in the frequency of repaired ruptures, unrepaired ruptures, or no ruptures between those with and without co-occurring major depressive disorder, χ²(2, N = 82) = 2.69, p = .26, or those with and without a history of childhood abuse, χ²(2, N = 81) = 0.57, p = .75. Unrepaired ruptures predicted worse treatment outcome (β = .44, p = .001). The current study underscores the importance of attending to discontinuities in alliance throughout treatment.

A Meta-Analytic Review of Prolonged Exposure for Posttraumatic Stress Disorder

Two decades of research demonstrate the efficacy of exposure therapy for posttraumatic stress disorder (PTSD). The efficacy of prolonged exposure (PE), a specific exposure therapy program for PTSD that has been disseminated throughout the world, has been established in many controlled studies using different trauma populations. However, a meta-analysis of the effectiveness of PE for PTSD has not been conducted to date. The purpose of the current paper is to estimate the overall efficacy of PE for PTSD relative to adequate controls. We included all published randomized controlled trials of PE vs. control (wait-list or psychological placebo) for the treatment of PTSD in adolescents or adults. Treatments were classified as PE if they included multiple sessions of imaginal and in vivo exposure and were based on the manualized treatment developed by Foa, Rothbaum, Riggs, and Murdock (1991). Thirteen studies with a total sample size of 675 participants met the final inclusion criteria. The primary analyses showed a large effect for PE versus control on both primary (Hedges’s g = 1.08) and secondary (Hedges’s g = 0.77) outcome measures. Analyses also revealed medium to large effect sizes for PE at follow-up, both for primary (Hedges’s g = 0.68) and secondary (Hedges’s g = 0.41) outcome measures. There was no significant difference between PE and other active treatments (CPT, EMDR, CT, and SIT). Effect sizes were not moderated by time since trauma, publication year, dose, study quality, or type of trauma. The average PE-treated patient fared better than 86% of patients in control conditions at post-treatment on PTSD measures. PE is a highly effective treatment for PTSD, resulting in substantial treatment gains that are maintained over time. (Reprinted with permission from Clinical Psychology Review 2010; 30:635–641)

Sudden gains in prolonged exposure for children and adolescents with posttraumatic stress disorder.

Our objective was to examine sudden gains during developmentally adjusted prolonged exposure for posttraumatic stress disorder (PTSD) among children and adolescents. We hypothesized that sudden gains would be detected and would be predictive of treatment outcome and follow-up. Sixty-three youngsters (ages 8-17) completed a developmentally adjusted protocol for the treatment of pediatric PTSD (Foa, Chrestman, & Gilboa-Schechtman, 2008). Participants' posttraumatic and depressive symptoms were assessed before each treatment session, as well as at approximately 3 and 12 months after treatment termination. We measured posttraumatic symptoms with the Child PTSD Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001) and measured depressive symptoms with the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and the Children's Depression Inventory (Kovacs, 1981, 1982). Sudden gains were found among 49.2% of participants and constituted 48.6% of the total reduction in posttraumatic symptoms. Compared to individuals who did not experience sudden gains, individuals who experienced sudden gains reported lower levels of posttraumatic symptoms, F(1, 61) = 14.4, p < .001, and depressive symptoms, F(1, 61) = 7.9, p < .01, at treatment termination. Differences in posttraumatic symptoms were maintained during both follow-up periods. Sudden gains are common in pediatric prolonged exposure for PTSD and are predictive of long-term outcome. Treatment planning can benefit from consideration of the intraindividual course of improvement, and treatment development may be enriched by understanding the mechanisms responsible for sudden gains.