PTSD: Treatment, Innovations, & Resources Amy W. Wagner, Ph.D. Portland VA Medical Center

PTSD: Treatment, PTSD: Treatment, Innovations, & ResourcesInnovations, & Resources

Amy W. Wagner, Ph.D.Amy W. Wagner, Ph.D.Portland VA Medical CenterPortland VA Medical Center

My PlanMy Plan

Provide brief overview of DSM-V Provide brief overview of DSM-V criteria for PTSDcriteria for PTSD

Discuss evidenced-based treatments Discuss evidenced-based treatments for PTSD and related problemsfor PTSD and related problems

Highlight key on-line resources for Highlight key on-line resources for you and your clients and cool you and your clients and cool innovationsinnovations

DSM-VDSM-V

“Just when I thought I knew what I was doing it all

changed again…”

Not so much, really.

Main Changes in DSM-V for Main Changes in DSM-V for PTSDPTSD

PTSD moved from the anxiety disorders to a PTSD moved from the anxiety disorders to a new class, “trauma and stressor-related new class, “trauma and stressor-related disorders”disorders”

Definition of “trauma” slightly changedDefinition of “trauma” slightly changed– No longer need “fear, helplessness, or horror” No longer need “fear, helplessness, or horror”

(A2)(A2)– Types of trauma (A1) somewhat narrowed (no Types of trauma (A1) somewhat narrowed (no

longer can include unexpected death of longer can include unexpected death of family/close friend due to natural causes)family/close friend due to natural causes)

Main Changes in DSM-V for Main Changes in DSM-V for PTSDPTSD

The 3 clusters of DSM-IV are now 5 clusters:The 3 clusters of DSM-IV are now 5 clusters:– IntrusionsIntrusions– AvoidanceAvoidance– Negative alterations in cognitions and moodNegative alterations in cognitions and mood– Alterations in arousal and reactivityAlterations in arousal and reactivity

New subtype: with dissociative symptomsNew subtype: with dissociative symptoms

Treatments for PTSDTreatments for PTSD

Treatments for PTSDTreatments for PTSD

Trauma-processing treatmentsTrauma-processing treatments– Facilitate the “working through” of traumatic Facilitate the “working through” of traumatic

experiencesexperiences– Trauma-focusedTrauma-focused

Skills-based treatmentsSkills-based treatments– Teach strategies for managing individual Teach strategies for managing individual

symptoms of PTSDsymptoms of PTSD– Present-focused (v. trauma-focused)Present-focused (v. trauma-focused)

Acceptance-oriented treatmentsAcceptance-oriented treatments– Newer to the fieldNewer to the field– Facilitate “living with” or “living despite” PTSD; i.e.,Facilitate “living with” or “living despite” PTSD; i.e.,

livingliving

PTSD: Trauma-Processing PTSD: Trauma-Processing TreatmentsTreatments

Prolonged Exposure Therapy (PE; Foa, Prolonged Exposure Therapy (PE; Foa, Hembree, & Rothbaum, 2007)Hembree, & Rothbaum, 2007)

Cognitive Processing Therapy (CPT; Cognitive Processing Therapy (CPT; Resick & Schnicke, 1993)Resick & Schnicke, 1993)

Eye Movement Desensitization and Eye Movement Desensitization and Reprocessing Therapy (EMDR; Shapiro, Reprocessing Therapy (EMDR; Shapiro, 2001)2001)

Prolonged ExposureProlonged Exposure

Based on emotional processing theory Based on emotional processing theory (combines classical conditioning theory (combines classical conditioning theory and an “information processing model” and an “information processing model” that links associations between stimuli, that links associations between stimuli, responses and meaning elements responses and meaning elements (beliefs)(beliefs)

The fear “network” must be activated The fear “network” must be activated and new associations must be learned to and new associations must be learned to the conditioned stimulithe conditioned stimuli

Prolonged ExposureProlonged ExposureCase FormulationCase Formulation

classically conditioned response classically conditioned response (associate (associate related things to the trauma, e.g. loud noises, related things to the trauma, e.g. loud noises, helicopters, crowded places)helicopters, crowded places)

negative thinkingnegative thinking (the world is dangerous, (the world is dangerous, I’m I’m incompetent) incompetent)

arousalarousal (heart racing, sweatiness)(heart racing, sweatiness)

avoidanceavoidance (of activities, work, open (of activities, work, open spaces, spaces, crowds) crowds)

PE: Fear Reduction ProcessPE: Fear Reduction Process

ApproachApproach to fear- to fear-eliciting stimuli or eliciting stimuli or memoriesmemories

PreventionPrevention of of avoidant avoidant behaviorsbehaviors

Incorporation of Incorporation of new informationnew information

Anxiety increases Anxiety increases initially, followed initially, followed by by reductionreduction

TimeFear

Prolonged ExposureProlonged Exposure

9-12 90-minute sessions9-12 90-minute sessions Education and orientationEducation and orientation Imaginal exposure (exposure to the Imaginal exposure (exposure to the

memories)memories) In vivoIn vivo exposure (exposure to avoided exposure (exposure to avoided

situations and activities)situations and activities) Stress tolerance and cognitive Stress tolerance and cognitive

restructuring throughoutrestructuring throughout Between session practiceBetween session practice

Cognitive Processing TherapyCognitive Processing Therapy

Largely based on a Largely based on a social-cognitivesocial-cognitive theory theory that suggests trauma alters that suggests trauma alters beliefsbeliefs in 5 key in 5 key areas: safety, trust, power/control, esteem, areas: safety, trust, power/control, esteem, & intimacy& intimacy

Emphasis on reconciling pre-existing beliefs Emphasis on reconciling pre-existing beliefs with new beliefs towards more balanced with new beliefs towards more balanced ways of viewing oneself, others, and the ways of viewing oneself, others, and the worldworld

Like PE, views activating the “fear network” Like PE, views activating the “fear network” importantimportant


Can be delivered individually, in group, or Can be delivered individually, in group, or bothboth

12 60-minute sessions (individual)12 60-minute sessions (individual) Education and orientationEducation and orientation Written “impact statement”Written “impact statement” Written trauma accountWritten trauma account Cognitive restructuringCognitive restructuring Between session homeworkBetween session homework


Two versions, full CPT and CPT without Two versions, full CPT and CPT without the written trauma narrative (“CPT-C”)the written trauma narrative (“CPT-C”)

New data suggest CPT-C just as effective New data suggest CPT-C just as effective in the long run with in the long run with quickerquicker change in the change in the short runshort run

Stay tuned!Stay tuned!

PTSD: Trauma Processing PTSD: Trauma Processing TherapiesTherapies

Recommended if:Recommended if:– Reasonable emotion regulation abilitiesReasonable emotion regulation abilities– Motivated for treatmentMotivated for treatment– Willing to focus on traumaWilling to focus on trauma

Not recommended if:Not recommended if:– Active substance dependenceActive substance dependence– High HI or SIHigh HI or SI– Other indicators of significant emotion dysregulationOther indicators of significant emotion dysregulation– Factors that would interfere with adhering to the Factors that would interfere with adhering to the

treatmenttreatment

Pause for PlugPause for Plug

The National Center for PTSD (VA) has a The National Center for PTSD (VA) has a wealth of invaluable and up-to-date wealth of invaluable and up-to-date resources for providers and clients:resources for providers and clients:

http://www.ptsd.va.gov/

Why should we consider a different Why should we consider a different approach to PTSD treatment?approach to PTSD treatment?

Substantial Substantial drop-outdrop-out among trauma- among trauma-focused treatmentsfocused treatments

Barriers exist to Barriers exist to engagementengagement in trauma- in trauma-focused treatmentsfocused treatments

Some populations show Some populations show preferencespreferences for for present-focused/skill-based interventions present-focused/skill-based interventions (Veterans, adolescents)(Veterans, adolescents)

Barriers exist to Barriers exist to implementationimplementation of of trauma-focused treatmentstrauma-focused treatments

PTSD: Skills-Based TreatmentsPTSD: Skills-Based Treatments

Based on premise that given the impact Based on premise that given the impact of trauma, existing means of coping are of trauma, existing means of coping are inadequateinadequate

Person must learn new means of Person must learn new means of managing thoughts/memories, emotions, managing thoughts/memories, emotions, and behaviorsand behaviors

Interventions are presented didactically, Interventions are presented didactically, often in group formatsoften in group formats

Data: Main PE outcome studies actually Data: Main PE outcome studies actually support present-focused treatmentssupport present-focused treatments

From: Foa, EB, Dancu, CV, Hembree, EA, et al. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumaticstress disorder in female assault victims. JCCP, 67, 194-200.

Data: Main PE outcome studies actually Data: Main PE outcome studies actually support present-focused treatmentssupport present-focused treatments

From: Schnurr, PP, Friedman, MJ, Engel, CC, Foa, EB, et al. (2007). Cognitive behavioraltherapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA, 297, 820-830.


Stress Inoculation Training Stress Inoculation Training (Meichenbaum, 1985)(Meichenbaum, 1985)

Portland VAMC (Campbell, Powch, Van Portland VAMC (Campbell, Powch, Van Male, Sardo)Male, Sardo)

Other approaches (e.g., Whealin, 2008a Other approaches (e.g., Whealin, 2008a and 2008b; VAPIHCS)and 2008b; VAPIHCS)


Individual SymptomsIndividual Symptoms

AngerAnger Chronic painChronic pain InsomniaInsomnia ““Stress”Stress” PanicPanic Interpersonal difficultiesInterpersonal difficulties Avoidance Avoidance


Often suggested as a “first step” Often suggested as a “first step” treatmenttreatment

Recommended for veterans who may not Recommended for veterans who may not be able to fully engage in trauma be able to fully engage in trauma processing therapiesprocessing therapies

Recommended for therapists who have Recommended for therapists who have not been trained in trauma processing not been trained in trauma processing therapies therapies

Acceptance-Oriented TreatmentsAcceptance-Oriented Treatments

Based on premise that significant suffering Based on premise that significant suffering stems from efforts to avoid or deny stems from efforts to avoid or deny experiences and emotionsexperiences and emotions

Teach methods for living with (PTSD) and Teach methods for living with (PTSD) and other intense emotional experiences towards other intense emotional experiences towards living life more fullyliving life more fully

Teach the capacity for living in the present Teach the capacity for living in the present moment, the opposite of focusing on past moment, the opposite of focusing on past traumatic experiences or potential future traumatic experiences or potential future threatsthreats


Dialectical Behavior Therapy (DBT; Dialectical Behavior Therapy (DBT; Linehan, 1993)Linehan, 1993)

Acceptance and Commitment Therapy Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999; (ACT; Hayes, Strosahl, & Wilson, 1999; Walser & Westrup, 2007)Walser & Westrup, 2007)

Acceptance-Oriented Treatments:Acceptance-Oriented Treatments:Dialectical Behavior TherapyDialectical Behavior Therapy

Comprehensive treatment for multi-Comprehensive treatment for multi-problemed individuals with severe emotion problemed individuals with severe emotion dysregulationdysregulation

Behavior therapy at the core with strong Behavior therapy at the core with strong emphasis on acceptance-based interventions emphasis on acceptance-based interventions (such as validation and mindfulness)(such as validation and mindfulness)

Particularly effective at reducing suicidal Particularly effective at reducing suicidal behaviorbehavior

Acceptance-Oriented Treatments:Acceptance-Oriented Treatments:Dialectical Behavior TherapyDialectical Behavior Therapy

Weekly individual and skills-based group Weekly individual and skills-based group therapy, plus phone consultation and therapy, plus phone consultation and therapist supporttherapist support

For those with “complex” presentations in For those with “complex” presentations in which uniform case formulation does not fitwhich uniform case formulation does not fit

Interesting new data on embedding PE Interesting new data on embedding PE within DBT for individuals with co-morbid within DBT for individuals with co-morbid PTSD (Harned & Linehan, 2008; Harned et PTSD (Harned & Linehan, 2008; Harned et al., 2012)al., 2012)

Acceptance-Oriented Treatments:Acceptance-Oriented Treatments:Acceptance and Commitment TherapyAcceptance and Commitment Therapy

12 sessions12 sessions

Increasing awareness: of one’s thought Increasing awareness: of one’s thought processes, experiences, values, and the processes, experiences, values, and the present momentpresent moment

Committed action: towards what matters Committed action: towards what matters (and despite what one thinks and feels)(and despite what one thinks and feels)

Support for efficacy with depression, Support for efficacy with depression, psychosis, substance abuse; being used with psychosis, substance abuse; being used with PTSDPTSD


For those who cannot tolerate pure change-For those who cannot tolerate pure change-oriented treatmentsoriented treatments

For those who still have some degree of For those who still have some degree of suffering after trauma-processing therapiessuffering after trauma-processing therapies

For those who do not wish to engage in For those who do not wish to engage in trauma processing therapiestrauma processing therapies

For relapse preventionFor relapse prevention For anyone wanting to live life more fully in For anyone wanting to live life more fully in

the presentthe present

Behavioral ActivationBehavioral ActivationFor Depression For Depression andand PTSD PTSD

(Martell, Addis, & Jacobson; Jakupcak & Wagner; (Martell, Addis, & Jacobson; Jakupcak & Wagner; Acierno et al.)Acierno et al.)

Based on premise that problems in vulnerable Based on premise that problems in vulnerable individuals' lives and behavioral responses reduce ability individuals' lives and behavioral responses reduce ability to experience positive reward from their environmentsto experience positive reward from their environments

Aims to systematically increase activation such that Aims to systematically increase activation such that patients may experience greater contact with sources of patients may experience greater contact with sources of reward in their livesreward in their lives and and solve life problemssolve life problems

Focuses directly on activation and on processes that Focuses directly on activation and on processes that inhibit activation, such as escape and avoidance inhibit activation, such as escape and avoidance behaviors and ruminative thinkingbehaviors and ruminative thinking

Resources & InnovationsResources & Innovations

National Center for PTSD National Center for PTSD http://www.ptsd.va.gov/

Afterdeployment.org (self-help for Afterdeployment.org (self-help for veterans and family members veterans and family members andand materials for providers)materials for providers)

http://www.afterdeployment.org/


National Center for Telehealth and National Center for Telehealth and TechnologyTechnology

http://t2health.org/

Great apps!! For clients and providersGreat apps!! For clients and providershttp://www.ptsd.va.gov/public/pages/PTSDCoach.asphttp://t2health.org/apps/provider-resilience


Portland Vet CenterPortland Vet Center

PTSD Clinical Team at the Portland VAPTSD Clinical Team at the Portland VA

Telehealth through the Portland VATelehealth through the Portland VA

Returning Veterans Project (Returning Veterans Project (http://www.returningveterans.org/index.php) )

Some options for “fee basis” reimbursement Some options for “fee basis” reimbursement through the VAthrough the VA

Documents

PTSD: Treatment, Innovations, & Resources Amy W. Wagner, Ph.D. Portland VA Medical Center