Integrating Acceptance-based Behavior Therapy into Exposure-based therapy for PTSD

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  • Integrating Acceptance-based Behavior Therapy into Exposure-based therapyfor PTSD

  • Acknowledgments

    Susan Orsillo, PhDSuffolk University

    Lizabeth Roemer, PhDUniversity of Massachusetts, Boston

  • The third wave Behavior TherapyCognitive TherapyAcceptance-based modelsAcceptance and Commitment Therapy (ACT)Mindfulness-based Cognitive Therapy (MBCT)Acceptance-based Behavior Therapy for GAD Dialectical Behavior Therapy (DBT)Integrative Behavioral Couple Therapy (IBCT)Behavioral Activation (BA)Functional Analytic Psychotherapy (FAP)Mindfulness-based Relapse Prevention (MBRP)

  • An etiological model of PTSD

    Generalized psychological vulnerabilityGeneralized biological vulnerabilityExperience of traumaDeveloped by classical conditioningMaintained by operant conditioningAnxious apprehensionAvoidance or numbing of emotional responseModerated by social support and ability to cope

    (Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)

  • Evidence-based psychological treatments for PTSDGeneral aimsExtinction of conditioned fear and anxiety responses through repeated, non-reinforced exposure to CSDevelopment of alternative, competing responses to anxiety and fearEmphasis on symptom reduction through mastery experiences and internal control strategies

  • Evidence-based treatments

    Exposure TherapyAnxiety Management Training (AMT)Combination treatments

    (Foa, Keane & Friedman, 2000; Keane et al, 2006; Roth & Fonagy, 2005)

  • Exposure Therapy

    Patient is guided through a vivid remembering of the trauma until extinction occurs

    Goal is to reduce avoidance of anxiety and promote control/mastery over trauma-related cues

    (Foa and Rothbaum, 1998)

  • Anxiety Management TrainingPackage of behavioral and cognitive strategies to reduce and control anxietyProgressive muscle relaxationDiaphragmatic breathingCognitive restructuringCommunication skills trainingTime managementAnger management/assertion training(Meichenbaum, 1994)

  • Combination treatmentsPackage of CT, exposure and emotion regulation skillsEssential components of CTSelf-monitoringIdentification and labeling of thoughts and associated emotionsCognitive restructuringChanging the content of a dysfunctional cognition through logical analysisHypothesis testingConducting behavioral experiments to evaluate the validity of dysfunctional thoughts

  • Combination treatments

    Cognitive Processing Therapy (CPT)Written exposure trialscognitive restructuring of trauma related erroneous cognitions and schemas, particularly regarding safety, trust, power, control, self-esteem and intimacySTAIRSEmotion regulation and distress tolerance skillsProlonged exposureCSA related PTSD

    (Resick et al. 2002; Cloitre et al., 2002)

  • The good news about EBTs for PTSDTreatments are efficacious when compared to TAU, wait list control and active placebo treatments67% of completers no longer meet criteria for PTSD56% of intent-to-treat patients no longer meet criteria for PTSD Exposure and CBT are generally equally efficacious

    (Bradley, 2005)

  • Limitations of current treatments44% of intent-to-treat patients continue to meet criteria for PTSD (Bradley, 2005)Using DSM criteria as treatment outcome may not be relevant to clinically significant changeGeneralization of findings limited by study exclusion rates averaging 30%Co-morbid Axis I disorderCurrent substance abuseSuicidal ideation or behavior

  • More limitationsRelative lack of effectiveness researchRCTs generally compare monotherapies and not multimodal therapieslack of evidence regarding long-term maintenance of gainsVast majority of community sample patients do not receive EBTsDue to lack of disseminationDue to lack of treatment acceptance by patients

  • And still moreLowest effect sizes for patients with combat-related PTSD compared to other traumasFocus on symptom reduction and not functional improvementInterpersonal relationshipsVocational functioningGeneral quality of life

  • Limitations specific to CBT

    Relatively difficult to train therapists to adherence (Kohlenberg, 2004; Dimidjian et al, 2006)Emphasis on control and mastery strategies can have paradoxical effect in anxiety disorders (Roemer & Borkovec, 1994)

  • Limitations specific to exposureRequires memory of a specific trauma eventMay have low acceptability to patients and providersPTSD patients have more negative attitudes toward emotional expressionExposure less effective for patients:High levels of anger at pre-treatmentHigh levels of avoidance at pre-treatmentPerpetrators of harm who experience guilt/shame as primary symptoms

  • Potential limitations of standard therapies for OIF/OEF veterans

    Stigma associated with mental health careReluctance to participate in exposurePresence of co-morbid conditionsLack of a single traumatic eventAssociated feelings of guilt, loss, anger, sadness, griefPotential for iatrogenic effects of exposure

  • The challenge in treating OIF/OEF veteransHow do we provide secondary prevention?Proper treatment may help prevent the development or progression of symptoms, or the underlying mechanisms leading to pathology (Zatzick et al. 2004)what are these mechanisms?What is the natural course of resilience, remission and recovery? (Bonanno 2004)How can we use current treatments in secondary prevention?How can we adapt or elaborate on these treatments for use with recently returned veterans?

  • Spectrum of Post-Deployment Mental Disorders (N = 46,571)Disorder N %PTSD20,63844%Drug Abuse17,76838%Depression14,317 31%Neurotic Disorders11,48125%Affective Psychosis 7,46016%Alcohol Dependence 3,116 7%Acute Stress Reaction 1,327 3%

    VHA Office of Public Health and Environmental Hazards, February 14, 2006

  • The cautionary tale of Critical Incident Stress Debriefing (CISD)

    Intervention intended as secondary prevention for occupational trauma exposure (Mitchell 1983;1993)Proprietary; dramatic claims of effectiveness Basic assumptions Exposure to traumatic stressor is sufficient to cause symptoms that can escalate to a pathological conditionEarly and proximal intervention involving emotional catharsis (exposure) is prophylactic

  • CISD proceduresFormatGroup administrationDelivered by a mental health provider assisted by non-professional peersConducted in one 2-3 hour session within 24-72 hours of traumatic eventMandatory attendance customaryNon-attendees or drop-outs typically retrieved by peer facilitator

  • CISD treatment protocolIntroduction of the debriefingStatement of facts regarding the traumatic eventDisclosure of thoughts regarding the eventDisclosure of emotional reactions, with focus on strong negative affectsSpecification of possible symptomsEducation regarding consequences of trauma exposurePlanned re-entry to social environment(Mitchell & Everly, 1993)

  • CISD outcome researchNo clinically significant improvement for participants at long-term follow-upSlight but statistically significant worsening on outcome measures for those accepting debriefingPreference for informal sources of support and assistance correlated strongly with improved outcomeThose with highest levels of both avoidance and intrusive recollection deteriorated most after debriefing; recovery better among those not receiving treatment (Mayou et al. 2000)CISD is inert at best and iatrogenic at worst (Lohr et al. 2003)

  • An etiological model of PTSD

    Generalized psychological vulnerabilityGeneralized biological vulnerabilityExperience of traumaDeveloped by classical conditioningMaintained by operant conditioningAnxious apprehensionAvoidance or numbing of emotional responseModerated by social support and ability to cope

    (Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)

  • Approaches to providing secondary preventionWatch and waitRespect the natural course of recovery among the resilientSupport naturally occurring restorative factors in patients lifeProvide supportive treatments that do not interfere with natural resilience and are not iatrogenicWellnessProvide treatments that enhance naturally occurring restorative factors Example: Behavioral Activation (BA)

  • Secondary prevention approaches

    RehabilitationSupport naturally occurring curative factors in patients life +Provide treatments that prevent or inhibit pathological mechanisms implicated in the development and maintenance of psychological distressExperiential avoidanceCo-morbid conditions that serve the function of experiential avoidance, especially SUDs and rumination

  • Acceptance-based Behavior Therapy (ABT)Standard therapiesBased on a conditioning model of PTSDAim is to reduce fear and anxiety through extinctionCoupled with strategies to change trauma-related thought contentAn alternative modelPTSD can be understood as a disorder of experiential avoidance (Hayes et al. 1999)Aim is to improve quality of lifeCoupled with strategies to change the process of cognition rather than the content(Orsillo & Batten 2005; Batten et al. 2005; Follette et al. 2004)

  • Experiential avoidanceAttempts to change the form or frequency of internal events (thoughts, feelings, memories, sensations) (Hayes et al. 1996)EA contributes to the development and maintenance of various forms of psychopathology, particularly anxiety disordersAnxiety disorders develop when individuals are unwilling to experience anxiety (and associated thoughts, images, distressing emotions)

  • A variety of external and internal control strategies are utilized to alleviate distress via escape and avoidanceBehavioral avoidance of situations and cues (CS) that elicit unwanted internal states (CR)Co