PTSD: National Center for PTSD
Prolonged Exposure for PTSD
Prolonged Exposure for PTSD
Prolonged Exposure (PE) is one of the most studied treatments for PTSD. Based on the large number of studies showing it is effective, PE has the strongest recommendation as a treatment for PTSD in every clinical practice guideline. PE is a trauma-focused psychotherapy that works to treat PTSD in patients with complicated presentations, including those with comorbidities such as substance use disorder.
PE, developed from Emotional Processing Theory (1), proposes that pathological fear structures develop after trauma in those who go on to have PTSD and that these pathological fear structures need to be modified for recovery to occur. Fear structures are made up of a stimulus (people, places, things, memories), followed by an emotional and/or physiological response and thoughts regarding the meaning of the stimulus and response. Fear structures become pathological when someone who has experienced a trauma (e.g., a gas explosion) experiences a stimulus that most people would consider safe (e.g., filling up gas at a gas station or memory/images of gas explosion), responds with a considerable distress (e.g., heart pounding, desire to flee and avoid the situation), and attributes extremely negative meaning about the self, others, or world (e.g., "This situation is extremely dangerous," "I can't handle this").
PE works to modify the fear structure through exposure and habituation to the feared but relatively safe stimulus (e.g., staying at a gas station or thinking about the memory until the distress response diminishes). Exposure to the stimulus activates the fear structure and allows the client to learn that:
- Memories and reminders of the trauma are not dangerous and can be experienced without significant distress.
- Distress does not last forever.
- Emotional responses gradually reduce with time even without doing anything.
- Responses (such as heart racing) are not dangerous.
- The client can handle negative affect.
Recovery from PTSD occurs as the fear structure is modified such that stimuli no longer elicit extreme negative responses or meanings.
PE is a manualized exposure-based psychological intervention designed to treat PTSD following trauma. PE is typically delivered in 8 to 15, 90-minute sessions, usually on a weekly basis. PE promotes emotional processing of the trauma memory through a deliberate systematic approach with traumaâ€related stimuli (2). The key components of PE are:
- Psychoeducation about treatment, common reactions to trauma, and breathing retraining.
- Imaginal exposure, which requires repeatedly retelling the trauma memory out loud (in present tense, eyes closed) and having the client listen to an audio recording of the session between treatment sessions.
- In-vivo exposure to places, things, and situations that are avoided because they evoke distress and anxiety.
- Emotional processing that focuses on reviewing the experience of exposure and its impact on thoughts related to the self, the world, and the trauma.
Overall and Relative Effectiveness
PE is one of the most researched interventions for PTSD. It has been studied in over 20 randomized clinical trials (RCTs) with more in progress (3). Meta-analyses (e.g., 4-7) suggest that PE produces large treatment effects in regard to PTSD symptom reduction and loss of diagnosis (e.g.,7).
The first RCT on PE was conducted by Foa and colleagues (1991) and examined the efficacy of PE compared to Stress Inoculation Training (SIT), supportive counseling (SC), and waitlist control (WL) among female survivors of sexual assault (8). Decreased PTSD symptoms were present for all groups posttreatment. At 3-month follow-up, the greatest reduction in PTSD symptoms was noted in the PE group. Resick and colleagues (2002) and Rothbaum, Astin, & Marsteller (2005) have also found PE to be superior to waitlist and equivalent to other trauma focused treatments in samples of female survivors of sexual assault (9,10). Based on intent to treat analyses, on average, 53% of those who initiate PE no longer meet diagnostic criteria for the disorder, and the rate of diagnostic change increases to 68% among individuals who complete treatment (11). Similarly, long-term follow-up data supports the efficacy of PE with 83% of patients who received PE no longer meeting diagnostic criteria six years following initial treatment (12).
A review by the Agency for Healthcare Research and Quality (13), which used extensive criteria for evaluating study quality, included 19 RCTs of PE. The review concluded that there is high strength of evidence to support the efficacy of exposure therapy such as PE for reduction of PTSD symptoms and depression symptoms, and loss of PTSD diagnosis and that trauma focused therapies such as PE are the most effective treatments for PTSD.
PE in Clinical Practice Guidelines
PE is recommended as a first-line treatment in all major PTSD treatment guidelines including the American Psychological Association, the International Society for Traumatic Stress Studies (ISTSS), the United Kingdom's National Institute for Health and Care Excellence (NICE), the U.S. Department of Veterans Affairs and Department of Defense (VA, DoD) and the Australian Guidelines (14).
Research with Military Personnel and Veterans
Schnurr and colleagues (2007) conducted the first RCT in female Veterans and demonstrated PE to be more efficacious than Present-Centered Therapy (15). At follow-up, individuals who completed PE demonstrated a greater reduction of PTSD symptoms and were 1.8 times more likely to no longer meet diagnostic criteria for PTSD. A recent head-to-head RCT in post-9/11 Veterans compared sertraline plus enhanced medication management, PE plus placebo, and PE plus sertraline (16). Results revealed significant reductions in PTSD symptom severity in both PE plus placebo and PE plus sertraline. Additional RCTs demonstrated effectiveness for reducing PTSD symptoms in U.S. military personnel (17), U.S. Veterans (e.g., 16,18-19), and Israeli Veterans (20).
Research with Comorbidities and Special Populations
PE is effective for reducing PTSD symptoms when comorbidities are present. As indicated in a meta-analytic review by Powers and colleagues (2010), PE is effective at reducing depression symptoms (21). For example, female survivors of sexual assault with a primary diagnosis of PTSD and comorbid depression experienced decreases in depressive symptomatology during the course of PE (9). Research examining PTSD and substance use disorder shows that PE integrated with or offered concurrently with substance use treatment is more effective for reducing PTSD symptoms, and in some studies substance use, than substance use only treatment (22-24). Additionally, PE has been effective in ameliorating trauma-related guilt (9,25), other non-fear emotions such as anger and shame (25) and improves regulation of emotion (26,27).
Since a large body of research has established that PE is effective for treating PTSD, newer studies are targeting ways to make PE more accessible and even more effective. For example, several studies are examining alternative models of care that provide the key elements of PE in massed or brief protocols (17,28-30). Result from a recent RCT demonstrated that massed PE (10 sessions over a two-week period) is not only well tolerated, but yield low dropout rates (17). Another novel RCT demonstrated that Prolonged Exposure for Primary Care which included four, 30-min appointments delivered over 4 to 6 weeks produced a large reduction in PTSD severity compared to a minimal contact control group (28). Such endeavors promise to increase patient access to effective intervention and retention in care.
- Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Bulletin, 99, 20-35. doi:10.1037/0033-2909.99.1.20
- Foa, E. B. (2011). Prolonged exposure therapy: Past, present, and future. Depression and Anxiety, 28, 1043-1047. doi:10.1002/da.20907
- O'Neil, M., McDonagh, M., Hsu, F., Cheney, T., Carlson, K., Holmes, R., ... Chou R. (in press). Pharmacologic and nonpharmacologic treatments for posttraumatic stress disorder: Groundwork for a publicly available repository of randomized controlled trials. Technical Brief. Rockville, MD: Agency for Healthcare Research and Quality, Forthcoming 2019
- Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews, 12, Art. No.:CD003388. doi:10.1002/14651858.CD003388.pub4
- Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., ... Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141. doi:10.1016/j.cpr.2015.10.003
- Jonas, D. E., Cusack, K., Forneris, C. A., Wilkins, T. M., Sonis, J., Middleton, J. C., ... Gaynes, B. N. (2013). Psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD). Comparative Effectiveness Review, No. 92. (Prepared by the RTI International-University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 12-EHC011-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2013. Retrieved from: www.effectivehealthcare.ahrq.gov/reports/final.cfm
- Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. The Journal of Clinical Psychiatry, 74, e541-e550. doi:10.2088/jcp.12r08225
- Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715-723. doi:10.1037//0022-006x.59.5.715
- Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867-879. doi:10.1037//0022-006x.70.4.867
- Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607-616. doi:10.1002/jts.20069
- Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227. doi:10.1176/appi.ajp.162.2.214
- Resick, P. A., Williams, L. F., Suvak, M. K., Monson, C. M., & Gradus, J. L. (2012). Long-term outcomes of cognitive-behavioral treatments for posttraumatic stress disorder among female rape survivors. Journal of Consulting and Clinical Psychology, 80, 201-210. doi:10.1037/a0026602
- Forman-Hoffman, V., Middleton, J. C., Feltner, C., Gaynes B. N., Weber, R.P., Bann, C., ... Green, J. (2018) Psychological and pharmacological treatments for adults with posttraumatic stress disorder: A systematic review update. Comparative Effectiveness Review, No. 207. (Prepared by the RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2015-00011-I for AHRQ and PCORI.) AHRQ Publication No. 18-EHC011-EF. PCORI Publication No. 2018-SR-01. Rockville, MD: Agency for Healthcare Research and Quality; May 2018. Retrieved from: www.effectivehealthcare.ahrq.gov/reports/final.cfm doi:10.23970/AHRQEPCCER207
- Hamblen, J. L., Norman, S. B., Sonis, J. H., Phelps, A. J., Bisson, J. I., Nunes, V. D., Megnin-Viggars, O., Forbes, D., Riggs, D. S., & Schnurr. P. P. (in press). A Guide to Guidelines for the Treatment of Posttraumatic Stress Disorder in Adults: An Update. Psychotherapy.
- Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., ... Turner, C. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA, 297, 820-830. doi:10.1001/jama.297.8.820
- Rauch, S. A., Kim, H. M., Powell, C., Tuerk, P. W., Simon, N. M., Acierno, R., ... Peterson, A. L. (2018). Efficacy of prolonged exposure therapy, sertraline hydrochloride, and their combination among combat Veterans with posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry. Advance online publication. doi:10.1001/jamapsychiatry.2018.3412
- Foa, E. B., McLean, C. P., Zang, Y., Rosenfield, D., Yadin, E., Yarvis, J. S., ... Fina, B. A. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. JAMA, 319, 354-364. doi:10.1001/jama.2017.21242
- Ford, J. D., Grasso, D. J., Greene, C. A., Slivinsky, M., & DeViva, J. C. (2018). Randomized clinical trial pilot study of prolonged exposure versus present centered affect regulation therapy for PTSD and anger problems with male military combat Veterans. Clinical Psychology & Psychotherapy, 25, 641-649. doi:10.1002/cpp.2194
- Rauch, S. A., King, A. P., Abelson, J., Tuerk, P. W., Smith, E., Rothbaum, B. O., ... Liberzon, I. (2015). Biological and symptom changes in posttraumatic stress disorder treatment: A randomized clinical trial. Depression and Anxiety, 32, 204-212. doi:10.1002/da.22331
- Nacasch, N., Foa, E. B., Huppert, J. D., Tzur, D., Fostick, L., Dinstein, Y., ... Zohar, J. (2011). Prolonged exposure therapy for combat-and terror-related posttraumatic stress disorder: A randomized control comparison with treatment as usual. Journal of Clinical Psychiatry, 72, 1174-1180. doi:10.4088/jcp.09m05682blu
- Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30, 635-641. doi:10.1016/j.cpr.2010.04.007
- Back, S. E., Foa, E. B., Killeen, T. K., Teesson, M., Mills, K. L., Cotton, B. D., & Carroll, K. M. (2014). Concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE): Therapist guide. Oxford University Press, USA.
- Roberts, N. P., Roberts, P. A., Jones, N., & Bisson, J. I. (2015). Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis. Clinical Psychology Review, 38, 25-38. doi:10.1016/j.cpr.2015.02.007
- Ruglass, L. M., Shevorykin, A., Radoncic, V., Smith, K. M., Smith, P. H., Galatzer-Levy, I. R., ... Hien, D. A. (2017). Impact of cannabis use on treatment outcomes among adults receiving cognitive-behavioral treatment for PTSD and substance use disorders. Journal of Clinical Medicine, 6, 14. doi:10.3390/jcm6020014
- Langkaas, T. F., Hoffart, A., Ã˜ktedalen, T., Ulvenes, P. G., Hembree, E. A., & Smucker, M. (2017). Exposure and non-fear emotions: A randomized controlled study of exposure-based and rescripting-based imagery in PTSD treatment. Behaviour Research and Therapy, 97, 33-42. doi:10.1016/j.brat.2017.06.007
- Jerud, A. B., Pruitt, L. D., Zoellner, L. A., & Feeny, N. C. (2016). The effects of prolonged exposure and sertraline on emotion regulation in individuals with posttraumatic stress disorder. Behaviour Research and Therapy, 77, 62-67. doi:10.1016/j.brat.2015.12.002
- Jerud, A. B., Zoellner, L. A., Pruitt, L. D., & Feeny, N. C. (2014). Changes in emotion regulation in adults with and without a history of childhood abuse following posttraumatic stress disorder treatment. Journal of Consulting and Clinical Psychology, 82, 721-730. doi:10.1037/a0036520
- Cigrang, J.A., & Peterson, A.L. (2017). Stepped-care approaches to posttraumatic stress disorder: Sharpening tools for the clinician's toolbox. Pragmatic Case Studies in Psychotherapy, 13, 142-153. doi:10.14713/pcsp.v13i2.2004
- Yasinski, C., Sherrill, A. M., Maples-Keller, J. L., & Rauch, S. A. (2018, January). Intensive outpatient prolonged exposure for PTSD in post-9/11 Veterans and Service-Members: Program structure and preliminary outcomes of the Emory Healthcare Veterans Program. Trauma Psychology News, 13(3). Retrieved from: traumapsychnews.com/2018/01/intensive-outpatient-prolonged-exposure-for-ptsd-in-post-9-11-veterans-and-service-members-program-structure-and-preliminary-outcomes-of-the-emory-healthcare-veterans-program/
- van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012). Examining potential contraindications for prolonged exposure therapy for PTSD. European Journal of Psychotraumatology, 3, 18805. doi:10.3402/ejpt.v3i0.18805
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