Empirically Supported Treatments for PTSD

Dr. Maite P. Mena

Behavioral Interventions for Anxiety Disorders

Cognitive Behavior Therapy (CBT) has been found to be an efficacious treatment for anxiety disorders including:

GADPTSDOCD

Becks negative cognitive triad

Negative view of self

Negative view of the world

Negative view of the future

Im no good Im useless Im inadequate

It will always be this way I will never get better Things will never work out for me

My problems are insurmountable People are cruel Everything is very difficult

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CBT is based on the cognitive model, which states that peoples emotions, behaviors, and physical reactions are influenced by how they perceive events. The principles of CBT are:

1)Formulate problem in cognitive terms: -What aspects of clients current thinking acts to maintain problematic emotions and behaviors? -Therapist might also be concerned with precipitating factors (context)- what environmental events might have influenced perceptions-Therapist would also be interested in developing hypotheses about key developmental events and enduring patterns of interpreting these events.

CBT Principles

2) Therapy requires a good therapeutic alliance-warmth, caring, genuine regardListening closelyEmpathizing Accurately summarize thoughts and emotions

CBT Principles

3) Collaboration and active participation--Encourage client to view therapy as teamwork-Assign work between sessions-Over time, give client more responsibility to direct session.

CBT Principles

4) Cognitive Therapy is goal-oriented and problem-focusedClient encouraged in initial session to develop a problem listSet specific goals of a behavioral nature-lonely- develop new friendships-develop plan, set HWIdentify thoughts interfering with goals

Principles-CBT

5) Present focused- here-and-now emphasis first (want to reduce symptom stress). Attention shifts to past when: a) client expresses strong desire, b) work on present problems produces little change in cognitions, emotions, behaviors, c) important dysfunctional ideas developed in the past (If I always do well, I am ok, if I dont do well I am not ok)

Principles-CBT

6) Cognitive therapists aim to educate the person so that they can be their own therapist (self-help) using the techniques learned in therapy.

7) Therapy is intended to be time-limited (4-14 sessions) however this is not always possible.

8) CBT is structured.

CBT-Principles

9) Cognitive therapy teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefsThe most basic question is to ask, What was going through your mind when _____?Then evaluate the validity of the thought via Socratic Questioning-Where is it written that what you told yourself is true, and even if it were true, is it really as bad as you tell yourself?CBT uses collaborative empiricism- helping determine accuracy of a thought.

CBT-Principles

10) Cognitive therapy use a variety of techniques to change thinking, mood and behavior. Emphasis in treatment also depends on disorder client is presenting with.

CBT

Therapist enters collaborative relationship with client.

The therapy is very structured and the session follows an agenda starting with review of homework and ending with a summary.

CBT

Therapist needs to focus on systematic errors in reasoning and restructure.Negative automatic thoughts disrupt ones mood. Leads to spiraling down.Distorted reasoning based on systematic logical errors. Therapy is an active process (eliciting self-talk/interpretations, gathering evidence against interpretation, setting up homework)

Automatic Thoughts

A spontaneously arising verbal or visual content of consciousness with symbolic representation.

Automatic thoughts are brief and patients are often more aware of the emotion they feel as a result of their thoughts than of the thoughts themselves.

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Negative Automatic Thoughts

Short, specific thoughts which often do not occur in sentences, but may consist of a few key words, images or memoriesSpontaneous and often extremely rapidNot the result of deliberation or reasoningAssociated with negative emotional reactionsGenerally appear reasonable at the time but usually involve more distortion of reality than other types of thinking

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Identifying and challenging cognitive distortions

First step is to identify negative beliefs.Write descriptions of situations where they experienced disturbing emotions.Document their emotions as these will give a clue as to the likely cognitive distortion underlying their difficult emotions.Write down negative thoughts.

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Behaviour

Symptoms

NegativeAutomatic Thought

Affect

Intermediate Belief

Core belief

Environment

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Identifying and Categorizing Core Beliefs (the therapist)

Mentally hypothesize where core belief specific automatic thoughts came fromSpecify the core beliefPresent hypothesis about the core belief to the patientEducate patient about core beliefs in general and about their core beliefsHelp patient specify and strengthen a new more adaptive core beliefBegin to evaluate and modify negative core beliefs with patient

Cognitive Restructuring

CBT holds that most of our emotions and behaviors are the result of what we think or believe about ourselves, other people, and the world. These cognitions shape how we interpret and evaluate what happens to us, influence how we feel about it, and provide a guide to how we should respond. Sometimes our interpretations, evaluations, and underlying beliefs thoughts contain distortions, errors, or biases, or are not very useful or helpful. Cognitive restructuring is a set of techniques for becoming more aware of our thoughts and for modifying them when they are distorted or are not useful. This approach does not involve distorting reality in a positive direction or attempting to believe the unbelievable. Rather, it uses reason and evidence to replace distorted thought patterns with more accurate, believable, and functional ones.

The term cognitive distortion refers to errors in thinking or patterns of thought that are biased in some way. They may include: (A) interpretations that are not very accurate and which selectively filter the available evidence, (B) evaluations that are harsh and unfair, and/or (C) expectations for oneself and for others that are rigid and unreasonable. The more a persons thinking is characterized by these distortions, the more they are likely to experience disturbing emotions and to engage in maladaptive behavior.

Some examples of common patterns of cognitive distortions are:

All-or-nothing thinking: Looking at things in absolute, black-and-white categories, instead of on a continuum. For example, if something is less than perfect, one sees it as a total failure.

Overgeneralization: Viewing a negative event as a part of a never-ending pattern of negativity while ignoring evidence to the contrary. Using words such as never, always, all, every, none, no one, nobody, or everyone.

Mental filter: Focusing on a single negative detail and dwelling it on it exclusively until ones vision of reality becomes darkened.

Magnification or minimization (e.g., magnifying the negative and minimizing the positive): Exaggerating the importance of ones problems and shortcomings. A form of this is called catastrophizing in which one tells oneself that an undesirable situation is unbearable, when it is really just uncomfortable or inconvenient.

Mind reading: Concluding what someone is thinking without any evidence, not considering other possibilities, and making no effort to check it out.

Emotional reasoning: Assuming that ones negative emotions necessarily reflect the way things really are (e.g., Because I feel it, it must be true. I feel stupid, therefore I am stupid).

Rigid rules (perfectionism). Having a precise, fixed idea of how oneself or others should behave, and overestimating how bad it is when these expectations are not met. Often phrased as "should" or must statements.

Unfair judgments: Holding oneself personally responsible for events that aren't (or arent entirely) under ones control, or blaming other people and overlooking ways in which one might have also contributed to the problem.

In CBT:

The therapist guides the client through the process of becoming more aware of what they are telling themselves and helps them to evaluate, and when appropriate, to modify their own thinking. The therapist teaches the client a process that will help them distinguish distorted thinking from more accurate and useful thinking. The therapist does not assume that the clients thoughts are distorted and instead attempts to guide the client with questions that encourage the client to make their own discoveries. Clients are also encouraged to practice this process on their own between sessions (homework).

CBT Homework

Homework is integral to CBT and the goal is to extend the opportunities for cognitive and behavioral change throughout the patients week. Tailor the assignment to the individualProvide sound rationaleUncover potential obstaclesModify relevant beliefs

Other behavioral interventions to treat Anxiety Disorders

Exposure Therapy, Systematic desensitization

Relaxation

Systematic desensitization

Developed by Joseph Wolpe in 1950sPatient creates hierarchy of 20-30 items of ascending fearfulnessDeep muscle relaxation practiced while imagining each scene repeatedly until it could be imagined without anxiety.Pairing of opposite emotional experiences (relaxation with anxiety-provoking stimuli) termed reciprocal inhibition.

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Systematic Desensitization

Systematic desensitization is a therapeutic intervention that reduces the learned link between anxiety and objects or situations that are typically fear-producing. The aim of systematic desensitization is to reduce or eliminate fears or phobias that sufferers find are distressing or that impair their ability to manage daily life. By substituting a new response to a feared situation, a trained contradictory response of relaxation which is irreconcilable with an anxious response phobic reactions are diminished or eradicated.

Exposure therapy

Developed by Marks, Gelder & Rachman in the late 60s and 70s.

Good results using graded exposure in vivo for phobias and OCD.

Flooding is exposure to feared stimulus at maximal intensity until anxiety habituates rapid & effective but very distressing for the patient.

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Exposure Therapy

Exposure is an important behavioral technique in the treatment of anxiety disorders.

Assumption is that anxiety is maintained by avoidance of the feared stimuli.

Exposure to the feared stimuli:Challenges the belief that there are negative consequences by coming into contact with the stimuliAllows physiological habituation.

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Exposure to what?

Posttraumatic Stress Disorder- expose to traumatic memories (1st) and avoided places, people, activities (2nd).

Obsessive Compulsive Disorder- expose to obsessive thoughts and triggers of compulsions with avoidance of compulsive behavior (response prevention).

Generalized Anxiety Disorder- expose to worries

Exposure therapy

Graded Hierarchy patient controlled and directed Anxiety is unpleasant but does no harm.As real as possible (imagination < in vivo) , to produce the greatest level of discomfort and anxiety that the patient is willing to experienceWithout internal or external distractionUntil anxiety goes away or is reduced by at least 50%. Anxiety eventually reduces.As frequent as possible practice makes perfect.

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Types of Exposure

In session exposure (imagined)In vivo exposure

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In session exposure

Patients imagine themselves coming into contact with the feared stimuli.

Described coming into contact with the feared stimuli onto a tape recorder with their eyes closed.

Re-expose themselves to this recording.

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In session exposure is used when:

Exposure to live situations is too anxiety generating for the patient to tolerate.Live exposure is impractical.Exposure is not immediately available.The queues are not external but are internal e.g. memories.

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In vivo exposure:

This is the best form of exposure and should be used wherever possible.Patients can normally initiate their own exposureInitially this may be modelled by the therapist to assist this process.Once initiated in a clinical setting the patient is encouraged to repeat this as frequently as possible outside the therapy sessions.

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Steps in conducting exposure

Preparation.Creation of exposure hierarchy.Initial exposure.Repeated exposure.

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Preparation for conducting exposure

Explain treatment rationale.Explore advantages and perceived disadvantages of doing exposure.Obtain, inform, consent and commitment to carrying out exposure.Explain that:Anxiety is unpleasant and does no harmAnxiety eventually reducesPractice makes perfect

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Creation of exposure hierarchy

The patient should describe all cues that evoke anxiety (alternatively describe the things they avoid) and create a listRate each item on a 0-100% scale0 being no discomfort/anxiety100 being maximum discomfort/anxietyCan rate in imaginable contactUse rating to rank list

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Initial Exposure

Graded exposure involves graduated exposure beginning with the item that produces least discomfort/anxiety and working up the scale. Habituation can take hours and sessions should be structured accordingly (initial exposure continued while another patient is being seen before the session may be continued). The patient should rate their anxiety/discomfort on a 0-100 scale every five minutes and exposure continued until anxiety has reduced by at least 50%.

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Repeated Exposure

This should be continued on at least a daily basisRecord each event as exposure is carried out.The patient moves up the hierarchy as they feel able.

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Relaxation techniques:Goals in relaxation

A coping mechanism to help patients gain a sense of mastery over their internal world

Aim is to facilitate engagement with activities of everyday living and exposure tasks.

Not an intrinsic therapeutic activity.

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Different types of relaxation

Progressive muscle relaxation.12 muscle group relaxation.8 muscle group relaxation.4 muscle group relaxation.Release only relaxation.

Breathing relaxation.Cue controlled relaxation.Holding the breath.Rhythmic breathing.Counting breaths.

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Relaxation method

Take a comfortable positionUsing fixed narrativeEncouraged to breath gentlyTense the area to the count of three breaths and then release slowly to the count of fivePause for 15 to 20 secondsProgressing to the next muscle group.At end counting down five to one visualising relaxation.Repeated using tape recorder.

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12 muscle group relaxation

These are:Lower arms.Upper arms.Lower legs.Thighs.Stomach.Upper chest and back.

Shoulders.Back of the neck.Lips.Eyes.Eye brows.Upper forehead and scalp.

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8 muscle group relaxation

1. Whole arms.2. Whole legs.3. Stomach.4. Upper chest and back.5. Shoulders.6. Back of the neck.7. Face.8. Forehead and scalp.

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4 muscle group relaxation

1. Whole arms.2. Upper chest and back.3. Shoulders and neck.4. Face.

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Relaxation key points

Focus on the physical sensation of tension and to gain mastery over this.

Use diaphragmatic breathing rather than light chest breathing which can lead to hyper-ventilation.

These breaths can be timed to the count of three.

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