Prolonged Exposure Therapy for Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is a constellation of symptoms that arise in the aftermath of a traumatic event. According to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PTSD includes combinations of the following symptoms that last for more than one month:
- Intrusive thoughts, flashbacks, and/or nightmares about the event
- Avoidance of thoughts, memories, people, places, and/or things that are reminders of the event
- Negative changes in thinking and mood, such as depression, hopelessness, anger, detachment, and/or feeling numb
- Hypervigilance, jumpiness, irritability, insomnia, recklessness, and/or difficulty concentrating (American Psychiatric Association [APA], 2013)
While rape victims and military veterans make up the majority of individuals who experience PTSD, it can result from any traumatic event such as child abuse or a car accident (APA, 2013). Posttraumatic stress disorder significantly impairs an individual’s ability to function and enjoy life. As such, it should be treated aggressively and with an evidence-based approach. Prolonged exposure (PE) therapy was developed by Dr. Edna Foa, Director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania. It is a form of psychotherapy based in the principals of cognitive behavioral therapy (CBT). Clinicians have been using the PE protocol for more than 20 years, there is ample empirical evidence to demonstrate its efficacy. Approximately 80% of patients who receive the treatment show significant improvement of PTSD symptoms (Center for the Treatment and Study of Anxiety, n.d.).
It is thought that PTSD occurs when an individual fails to process his or her trauma memory. Thus, the purpose of PE is to help the individual process those memories in a controlled way so that they no longer induce a fear response (Foa, 2011). The treatment involves weekly 90-minute therapy sessions for two to three months. The protocol uses two types of exposure: imaginal and in vivo.
During the imaginal exposure, the patient closes his or her eyes and recounts the story of the trauma memory multiple times during the session. Afterwards, the client and therapist discuss the emotions and thoughts stemming from revisiting the trauma. In addition, the therapist records the patient while he or she narrates the memory, and then the patient listens to the recording at home between therapy sessions (National Center for PTSD, 2009). According to Foa (2011), this strategy “…is designed to help patients organize the memory, [reexamine] negative perceptions about their conduct during the trauma, regain new perspectives about themselves and others, distinguish between thinking about the trauma and reexperiencing the trauma, generate habituation to the trauma memory so that the trauma can be remembered without causing undue anxiety, and foster the realization that engaging in the trauma memory does not result in harm” (p. 1045). An in vivo exposure is homework that the client completes outside of the therapy session. Together with the therapist, the client makes a list of safe but anxiogenic situations or objects that he or she avoids. The client then confronts those situations or objects and stays in them until his or her anxiety subsides (National Center for PTSD, 2009). The premise behind these activities, according to Foa, is to activate the trauma memory and then “[disconfirm] the expected ‘disasters’” (p. 1045).
Unfortunately, PE therapy is unlikely to complete “cure” PTSD, and some symptoms may linger. It is also possible for a PTSD patient to relapse even after successfully completing the treatment (Foa, 2011, p. 1046). This fact speaks more to the insidiousness of PTSD rather than a specific deficiency in the treatment protocol; however, it does encourage research to continue to refine the treatment.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Foa, E.B. (2011). Prolonged exposure therapy: Past, present, and future. Depression and Anxiety, 28(12): 1043–1047. Retrieved from http://rdcu.be/trAR/
National Center for PTSD. (2009, September 29). Prolonged Exposure Therapy for PTSD. Retrieved from https://www.ptsd.va.gov/public/treatment/therapy-med/prolonged-exposure-therapy.asp
Center for the Treatment and Study of Anxiety. (n.d.). About Prolonged Exposure Therapy. Retrieved from http://www.med.upenn.edu/ctsa/workshops_pet.html