Prolonged Exposure for PTSD - PTSD: National Center for PTSD
Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

PTSD: National Center for PTSD

Menu
Menu

Quick Links

Veterans Crisis Line Badge
My healthevet badge
EBenefits Badge
 

Prolonged Exposure for PTSD

Share this page

Prolonged Exposure for PTSD

Lauren B. McSweeney, PhD, Sheila A. M. Rauch, PhD, Sonya B. Norman, PhD, & Jessica L. Hamblen, PhD

Prolonged Exposure (PE) is one of the most studied treatments for PTSD. Based on the large number of studies showing it is effective for use across diverse patient presentations, 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.

Continuing Education Course

Prolonged Exposure Therapy: Effective Treatment for PTSD

This PTSD 101 online course describes research support for PE, session content and use with complex patient presentations.

Theoretical Model

PE, developed from Emotional Processing Theory (1), proposes that pathological fear and other emotional structures develop after trauma in those who go on to have PTSD and that these pathological fear/emotion structures need to be modified for recovery to occur. Fear/emotion 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/emotion 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/emotion structure through exposure and habituation to the feared (or avoided due to another negative emotional reaction) 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 structure and allows the client to learn that:

  1. Memories and reminders of the trauma are not dangerous and can be experienced without significant distress.
  2. Distress does not last forever.
  3. Emotional responses gradually reduce with time even without doing anything.
  4. Responses (such as heart racing) are not dangerous.
  5. The client can handle negative affect.

Recovery from PTSD occurs as the fear/emotion structure is modified such that stimuli no longer elicit extreme negative responses or meanings.

Back to Top

Session Content

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 trauma‐related stimuli (2). The key components of PE are:

  1. Psychoeducation about common reactions to trauma, what maintains trauma-related symptoms, and how PE reduces PTSD symptoms
  2. Repeated in-vivo confrontation with situations, people or objects that the patient is avoiding because they are trauma-related and cause emotional distress, such as anxiety, shame or guilt.
  3. Repeated, imaginal exposure to the trauma memories (i.e., revisiting and recounting the trauma memory in imagery) followed by processing the details of the event, the emotions and the thoughts that the patient experienced during the trauma.

Back to Top

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.

Back to Top

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).

Back to Top

Research Across Diverse Populations

The intersectionality of race/ethnicity, gender, sexual orientation and class are important considerations in any mental health practice, including PE. Individuals who experience race-based traumas and bias motivated violence (i.e., hate crimes) often experience posttraumatic symptoms such as shame, self-blame and greater levels of negative psychosocial symptoms, including PTSD (15,16). The individualized nature of PE treatment allows culturally competent providers to integrate these issues in the standard PE format. For example, excellent resources are available for possible adaptations of PE among Black patients, including assessment of and attention to race-based trauma as the origin of PTSD (17).

A recent review of clinical trials in PE found that Black patients have been well represented in PE clinical trials though other groups of color are underrepresented (18). Of note, McClendon et al. (2020) concluded in their review of the impact of race/ethnicity on PTSD treatment that race/ethnicity do not appear to impact magnitude of change but may impact initiation and retention (19). Thus, providers should be especially aware of access and retention issues when working with patients of color.

Back to Top

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 (20). 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 (21). 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 (22), U.S. Veterans (e.g., 21,23,24), and Israeli Veterans (25).

Back to Top

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 (26). 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 (27-29). Additionally, PE has been effective in ameliorating trauma-related guilt (9,30), other non-fear emotions such as anger and shame (30) and improves regulation of emotion (31,32).

Back to Top

Emerging Issues

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 (22,33-35). 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 (22). 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 (33). Such endeavors promise to increase patient access to effective intervention and retention in care.

Learn about In Vivo Exposures for Prolonged Exposure Therapy During a Pandemic as a way to creatively offer Prolonged Exposure during times of pandemic-related activity.

Back to Top

References

  1. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Bulletin, 99(1), 20-35. https://doi.org/10.1037/0033-2909.99.1.20
  2. Foa, E. B. (2011). Prolonged exposure therapy: Past, present, and future. Depression and Anxiety, 28(12), 1043-1047. https://doi.org10.1002/da.20907
  3. O'Neil, M., McDonagh, M., Hsu, F., Cheney, T., Carlson, K., Holmes, R., Ramirez, S., Hart, E., Murphy, K., Graham, E., & Chou R. (2019, May). Pharmacologic and nonpharmacologic treatments for posttraumatic stress disorder: Groundwork for a publicly available repository of randomized controlled trials. Technical Brief No. 32. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 19-EHC018-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2019. Posted final reports are located on the Effective Health Care Program search page. https://doi.org/10.23970/AHRQEPCTB32.
  4. 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. https://doi.org/10.1002/14651858.CD003388.pub4
  5. Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., Feltner, C>, Brownley, K. A., Olmsted, K. R., Greenblatt, A., Weil, A., & Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141. https://doi.org/10.1016/j.cpr.2015.10.003
  6. Jonas, D. E., Cusack, K., Forneris, C. A., Wilkins, T. M., Sonis, J., Middleton, J. C., Feltner, C., Meredith, D., Cavanaugh, J., Brownley, K. A., Olmsted, K. R., Greenblatt, A., Weil, A., & Gaynes, B. N. (2013, May). 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
  7. 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(6), e541-e550. https://doi.org/10.2088/jcp.12r08225
  8. 8. 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(5), 715-723. https://doi.org/10.1037//0022-006x.59.5.715
  9. 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(4), 867-879. https://doi.org/10.1037//0022-006x.70.4.867
  10. 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(6), 607-616. https://doi.org/10.1002/jts.20069
  11. Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162(2), 214-227. https://doi.org/10.1176/appi.ajp.162.2.214
  12. 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(2), 201-210. https://doi.org/10.1037/a0026602
  13. Forman-Hoffman, V., Middleton, J. C., Feltner, C., Gaynes B. N., Weber, R.P., Bann, C., Viswanathan, M., Lohr, K. N., Phil, M., Baker, C., &Green, J. (2018, May) 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
  14. 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. (2019). A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy, 56(3), 359-373. https://doi.org/10.1037/pst0000231
  15. Bryant-Davis, T., & Ocampo, C. (2005). Racist incident-based trauma. The Counseling Psychologist, 33(4), 479-500. https://doi.org/10.1177/0011000005276465
  16. Carter, R. T. (2007). Racism and psychological and emotional injury. The Counseling Psychologist, 35(1), 13-105. https://doi.org/10.1177/0011000006292033
  17. Williams, M. T., Malcoun, E., Sawyer, B. A., Davis, D. M., Nouri, L. B., & Bruce, S. L. (2014). Cultural adaptations of prolonged exposure therapy for treatment and prevention of posttraumatic stress disorder in African Americans. Behavioral Sciences, 4(2), 102-124. https://doi.org/10.3390/bs4020102
  18. Benuto, L. T., Bennett, N. M., & Casas, J. B. (2020) Minority participation in randomized controlled trials for prolonged exposure therapy: A systematic review of the literature. Journal of Traumatic Stress, 33(4), 420-431. https://doi.org/10,1002/jts,22539
  19. McClendon, J., Dean, K. E., & Galovski, T. (2020). Addressing diversity in PTSD treatment: Disparities in treatment engagement and outcome among patients of color. Current Treatment Options in Psychiatry, ISSN: 2196-3061. https:/doi.org/10.1007/s40501-020-00212-0
  20. Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., Resick, P. A., Thurston, V., Orsillo, S. M., Haug, R., Turner, C., & Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA, 297(8), 820-830. https://doi.org/10.1001/jama.297.8.820
  21. Rauch, S. A., Kim, H. M., Powell, C., Tuerk, P. W., Simon, N. M., Acierno, R., Allar, C. B., Norman, S. B., Venners, M. R., Rothbaum, B. O., Stein, M. B., Porter, K., Martis, B., King, A. P., Liberson, Is., Phan, K. L., & Hoge, C. W.. (2019). Efficacy of prolonged exposure therapy, sertraline hydrochloride, and their combination among combat Veterans with posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 76(2), 117-126. https://doi.org/10.1001/jamapsychiatry.2018.3412
  22. Foa, E. B., McLean, C. P., Zang, Y., Rosenfield, D., Yadin, E., Yarvis, J. S., Mintz, J., Young-McCaughan, S., Borah, E. V., Dondanville, K. A., Fina, B. A., Hall-Clark, B. N., Lichner, T., Litz, B. T., Roache, J., Wright, E. C., & Peterson, A. L., for the STRONG STAR Consortium. (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(4), 354-364. https://doi.org/10.1001/jama.2017.21242
  23. 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(5), 641-649. https://doi.org/10.1002/cpp.2194
  24. Rauch, S. A., King, A. P., Abelson, J., Tuerk, P. W., Smith, E., Rothbaum, B. O., Clifton, E., Defever, A., & Liberzon, I. (2015). Biological and symptom changes in posttraumatic stress disorder treatment: A randomized clinical trial. Depression and Anxiety, 32(3), 204-212. https://doi.org/10.1002/da.22331
  25. Nacasch, N., Foa, E. B., Huppert, J. D., Tzur, D., Fostick, L., Dinstein, Y., Polliack, M., & 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(9), 1174-1180. https://doi.org/10.4088/jcp.09m05682blu
  26. 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(6), 635-641. https://doi.org/10.1016/j.cpr.2010.04.007
  27. 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.
  28. 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. https://doi.org/10.1016/j.cpr.2015.02.007
  29. Ruglass, L. M., Shevorykin, A., Radoncic, V., Smith, K. M., Smith, P. H., Galatzer-Levy, I. R., Papini, S., & 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(2), 14. https://doi.org/10.3390/jcm6020014
  30. Langkaas, T. F., Hoffart, A., Øktedalen, 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. https://doi.org/10.1016/j.brat.2017.06.007
  31. 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. https://doi.org/10.1016/j.brat.2015.12.002
  32. 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(4), 721-730. https://doi.org/10.1037/a0036520
  33. 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(2), 142-153. https://doi.org/10.14713/pcsp.v13i2.2004
  34. 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. 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/
  35. 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(1), 18805. https://doi.org/10.3402/ejpt.v3i0.18805

You May Also Be Interested In

A stack of documents

VA/DoD Clinical Practice Guideline for PTSD (2017)

Get information on evidence based psychotherapies for PTSD.

A doctor handing a prescription.

Clinician's Guide to Medications for PTSD

Get key information and guidance on the best medications for PTSD.

Are you treating Veterans with PTSD? We can help. PTSD Consultation Program for providers who treat veterans.

PTSD Consultation Program

Expert guidance for treating Veterans with PTSD.

Get help for PTSD

If you need help right away:

FacebookTwitterYouTube

PTSD Information Voice Mail:
(802) 296-6300
ncptsd@va.gov
Also see: VA Mental Health

Site Map