Transcript Supervision!! Amy W. Wagner, Ph.D.

PTSD: Treatment, Innovations,
& Resources
Amy W. Wagner, Ph.D.
Portland VA Medical Center
My Plan
 Provide
brief overview of DSM-V criteria
for PTSD
 Discuss
evidenced-based treatments for
PTSD and related problems
 Highlight
key on-line resources for you
and your clients and cool innovations
DSM-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 PTSD
 PTSD
moved from the anxiety disorders to a new
class, “trauma and stressor-related disorders”
 Definition
of “trauma” slightly changed
– No longer need “fear, helplessness, or horror” (A2)
– Types of trauma (A1) somewhat narrowed (no longer
can include unexpected death of family/close friend due
to natural causes)
Main Changes in DSM-V for PTSD
 The
–
–
–
–
3 clusters of DSM-IV are now 5 clusters:
Intrusions
Avoidance
Negative alterations in cognitions and mood
Alterations in arousal and reactivity
 New
subtype: with dissociative symptoms
Treatments for PTSD
Treatments for PTSD
 Trauma-processing
treatments
– Facilitate the “working through” of traumatic experiences
– Trauma-focused
 Skills-based
treatments
– Teach strategies for managing individual symptoms of
PTSD
– Present-focused (v. trauma-focused)
 Acceptance-oriented
treatments
– Newer to the field
– Facilitate “living with” or “living despite” PTSD; i.e., living
PTSD: Trauma-Processing Treatments

Prolonged Exposure Therapy (PE; Foa,
Hembree, & Rothbaum, 2007)

Cognitive Processing Therapy (CPT; Resick &
Schnicke, 1993)

Eye Movement Desensitization and
Reprocessing Therapy (EMDR; Shapiro, 2001)
Prolonged Exposure

Based on emotional processing theory
(combines classical conditioning theory and an
“information processing model” that links
associations between stimuli, responses and
meaning elements (beliefs)

The fear “network” must be activated and new
associations must be learned to the conditioned
stimuli
Prolonged Exposure
Case Formulation
classically conditioned response (associate related things
to the trauma, e.g. loud noises, helicopters, crowded places)
negative thinking (the world is dangerous, I’m
incompetent)
arousal (heart racing, sweatiness)
avoidance (of activities, work, open spaces,
crowds)
PE: Fear Reduction Process
to feareliciting stimuli or
memories
 Prevention of
avoidant behaviors
 Incorporation of
new information
 Anxiety increases
initially, followed by
reduction
Fear
 Approach
Time
Prolonged Exposure
9-12 90-minute sessions
 Education and orientation
 Imaginal exposure (exposure to the memories)
 In vivo exposure (exposure to avoided
situations and activities)
 Stress tolerance and cognitive restructuring
throughout
 Between session practice

Cognitive Processing Therapy

Largely based on a social-cognitive theory that
suggests trauma alters beliefs in 5 key areas:
safety, trust, power/control, esteem, & intimacy

Emphasis on reconciling pre-existing beliefs with
new beliefs towards more balanced ways of
viewing oneself, others, and the world

Like PE, views activating the “fear network”
important
Cognitive Processing Therapy
Can be delivered individually, in group, or both
 12 60-minute sessions (individual)
 Education and orientation
 Written “impact statement”
 Written trauma account
 Cognitive restructuring
 Between session homework

Cognitive Processing Therapy

Two versions, full CPT and CPT without the
written trauma narrative (“CPT-C”)

New data suggest CPT-C just as effective in the
long run with quicker change in the short run

Stay tuned!
PTSD: Trauma Processing Therapies

Recommended if:
– Reasonable emotion regulation abilities
– Motivated for treatment
– Willing to focus on trauma

Not recommended if:
–
–
–
–
Active substance dependence
High HI or SI
Other indicators of significant emotion dysregulation
Factors that would interfere with adhering to the treatment
Pause for Plug
The National Center for PTSD (VA) has a wealth
of invaluable and up-to-date resources for
providers and clients:
http://www.ptsd.va.gov/
Why should we consider a different
approach to PTSD treatment?
Substantial drop-out among trauma-focused
treatments
 Barriers exist to engagement in trauma-focused
treatments
 Some populations show preferences for presentfocused/skill-based interventions (Veterans,
adolescents)
 Barriers exist to implementation of traumafocused treatments

PTSD: Skills-Based Treatments

Based on premise that given the impact of
trauma, existing means of coping are
inadequate

Person must learn new means of managing
thoughts/memories, emotions, and behaviors

Interventions are presented didactically, often
in group formats
Data: Main PE outcome studies actually support
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 posttraumatic
stress disorder in female assault victims. JCCP, 67, 194-200.
Data: Main PE outcome studies actually support
present-focused treatments
From: Schnurr, PP, Friedman, MJ, Engel, CC, Foa, EB, et al. (2007). Cognitive behavioral
therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA,
297, 820-830.
PTSD: Skills-Based Treatments

Stress Inoculation Training (Meichenbaum,
1985)

Portland VAMC (Campbell, Powch, Van Male,
Sardo)

Other approaches (e.g., Whealin, 2008a and
2008b; VAPIHCS)
PTSD: Skills-Based Treatments
Individual Symptoms
Anger
 Chronic pain
 Insomnia
 “Stress”
 Panic
 Interpersonal difficulties
 Avoidance

PTSD: Skills-Based Treatments

Often suggested as a “first step” treatment

Recommended for veterans who may not be
able to fully engage in trauma processing
therapies

Recommended for therapists who have not
been trained in trauma processing therapies
Acceptance-Oriented Treatments

Based on premise that significant suffering stems
from efforts to avoid or deny experiences and
emotions

Teach methods for living with (PTSD) and other
intense emotional experiences towards living life
more fully

Teach the capacity for living in the present
moment, the opposite of focusing on past
traumatic experiences or potential future threats
Acceptance-Oriented Treatments

Dialectical Behavior Therapy (DBT; Linehan,
1993)

Acceptance and Commitment Therapy (ACT;
Hayes, Strosahl, & Wilson, 1999; Walser &
Westrup, 2007)
Acceptance-Oriented Treatments:
Dialectical Behavior Therapy

Comprehensive treatment for multi-problemed
individuals with severe emotion dysregulation

Behavior therapy at the core with strong
emphasis on acceptance-based interventions
(such as validation and mindfulness)

Particularly effective at reducing suicidal
behavior
Acceptance-Oriented Treatments:
Dialectical Behavior Therapy

Weekly individual and skills-based group therapy,
plus phone consultation and therapist support

For those with “complex” presentations in which
uniform case formulation does not fit

Interesting new data on embedding PE within DBT
for individuals with co-morbid PTSD (Harned &
Linehan, 2008; Harned et al., 2012)
Acceptance-Oriented Treatments:
Acceptance and Commitment Therapy

12 sessions

Increasing awareness: of one’s thought processes,
experiences, values, and the present moment

Committed action: towards what matters (and
despite what one thinks and feels)

Support for efficacy with depression, psychosis,
substance abuse; being used with PTSD
Acceptance-Oriented Treatments





For those who cannot tolerate pure changeoriented treatments
For those who still have some degree of suffering
after trauma-processing therapies
For those who do not wish to engage in trauma
processing therapies
For relapse prevention
For anyone wanting to live life more fully in the
present
Behavioral Activation
For Depression and PTSD
(Martell, Addis, & Jacobson; Jakupcak & Wagner; Acierno et al.)

Based on premise that problems in vulnerable
individuals' lives and behavioral responses reduce ability
to experience positive reward from their environments

Aims to systematically increase activation such that
patients may experience greater contact with sources of
reward in their lives and solve life problems

Focuses directly on activation and on processes that
inhibit activation, such as escape and avoidance
behaviors and ruminative thinking
Resources & Innovations

National Center for PTSD
http://www.ptsd.va.gov/
Afterdeployment.org (self-help for veterans
and family members and materials for
providers)
http://www.afterdeployment.org/

Resources & Innovations
National Center for Telehealth and
Technology
http://t2health.org/

Great apps!! For clients and providers
http://www.ptsd.va.gov/public/pages/PTSDCoa
ch.asp
http://t2health.org/apps/provider-resilience

Resources & Innovations

Portland Vet Center

PTSD Clinical Team at the Portland VA

Telehealth through the Portland VA

Returning Veterans Project
(http://www.returningveterans.org/index.php)

Some options for “fee basis” reimbursement through
the VA