The European Network for Traumatic Stress Training

1
The European Network for Traumatic
StressTraining Practice

• www.tentsproject.eu

2
Cognitive Therapy and the treatment of PTSD and
ASD

• Chris Freeman MD

3
Contents

• What is CBT
• General principles of psychological treatment
• A typical course of treatment
• Evidence base for CBT in PTSD
• Evidence base for CBT in Acute stress disorder
• CBT compared with other psychological treatments
  and drugs

4
What is CBT

• Several different models of CBT but all share
  some common characteristics
• Even EMDR has some CBT principles but it will be
  covered in a separate set of slides
• Brief Eclectic Therapy (BEP) has some CBT
  techniques but is a separate psychotherapy
  despite being grouped with CBT by NICE. (National
  Institute of Clinical Excellence UK)

5
General principles of psychological treatment

• Assessment and formulation is crucial
• This should be carried out before ASD and PTSD
  treatment.

6
CBT for PTSD. The Evidence
7
Ways of changing trauma memories How CBT models
differ.

• Prolonged exposure to trauma memory (Foa
  imaginal reliving Resick trauma narrative)
• Updating worst moments in memory (Ehlers Clark)
• Brief exposure to image with rapid eye movements
  or other bilateral stimulation (Shapiro)
• In vivo exposure
• Discrimination of triggers (Ehlers Clark)

8
Evidence Base reviewed by NICE

• EMDR 11 studies compared with W/L or other
  psychological interventions
• CBT 16 studies compared with W/L or other
  psychological interventions
• ECBT 16 studies compared with W/L or other
  psychological interventions
• SM 7 studies compared with W/L or other
  psychological interventions
• GCBT 4 studies compared with W/L or other
  psychological interventions
• Other 6 studies compared with W/L or other
  psychological interventions

9
NICE Guidelines 2005 Systematic Review of
Psychological Treatments for PTSD Effect
sizes compared to wait list
13 RCTs
4 RCTs
3 RCTs
A priori threshold d .08
2 RCTs
10
Psychological Interventions

• Exposure based CBT demonstrated more clinically
  important effects on self report PTSD symptoms
  and PTSD diagnosis than W/L.
• Limited evidence of superiority on clinician
  rated PTSD symptoms , depression and anxiety
• Not superior to stress management or other
  treatments and outcomes varied substantially

11
Psychological Interventions

• EMDR found support but not as strong as TFCBT
• Clinically important benefits on clinician rated
  but not self report PTSD symptoms compared to W/L
• Limited evidence for clinically important effects
  on anxiety and depression
• EMDR was superior to supportive/non-directive
  therapy but not stress management.

12
Evidence base since NICE

• Several new studies but no change in conclusions
  above
• 4 additional studies comparing trauma focussed
  CBT with waiting list
• I additional study comparing trauma focussed CBT
  with other treatment

13
Recommendations from evidence base 1

• All PTSD sufferers should be offered a course of
  trauma focused psychological therapy on an
  individual, out-patient basis (A)
• Trauma focused psychological interventions should
  be offered regardless of the time elapsed since
  the trauma (B)

14
Recommendations from evidence base 2

• CBT should be offered even if key trauma was a
  long time ago
• Individual face to face therapy is first choice
• Course of treatment for a single trauma is 8-12
  60 min. sessions
• Treatment must be flexible with longer sessions
  if trauma story being related.

15
Recommendations from evidence base 3

• Trauma focused psychological interventions should
  be 8-12 sessions long when the PTSD has arisen
  from a single incident. (B)
• If the traumatic event is being discussed
  sessions should be longer (90 mins), offered on a
  regular and continuous basis (weekly) with the
  same person. (B)

16
Recommendations from evidence base 4

• In cases of multiple trauma, traumatic
  bereavement, chronic disability arising from the
  trauma, significant co-morbidity or social
  problems longer treatment duration should be
  considered (gt 12 sessions). (C)
• Treatment should be delivered by competent
  individuals with appropriate training and
  supervision. (C)

17
Acute Stress Disorder (ASD)

• Evidence recently reviewed by Roberts 2009
• Evidence supports effectiveness of trauma
  focussed CBT over control
• Self help booklets are not superior to control
  condition (Ehlers 2003)
• Studies that offer brief treatment (5 sessions)
  treat ASD and PTSD symptoms but not depression
  or anxiety.
• Need longer treatment 12 hours to treat wider
  symptoms

18
Acute Stress Disorder

• Studies have tended to treat patients in first 3
  months so subjects are a combination of ASD and
  acute PTSD
• Evidence base is very similar to PTSD but fewer
  studies

19
ASD

• Sessions should be 90 minutes long if using
  imaginal exposure
• Combination treatments should not be used
• Treatment should be individual not group
• Treatment should not begin within 2 weeks of the
  trauma

20
Training for therapy

• Used to assumed that therapists needed to be
  competent in general CBT and then trained in
  Trauma Focussed CBT
• Northern Ireland studies show this may not be
  necessary

21
Drug treatment compared with psychotherapy

• No head to head trials so we have to assess drug
  trial evidence separately and compare at a
  clinical level

22
What are essential ingredients

• Trauma focussed
• Target trauma memories
• Target trauma beliefs and meanings
• Provide exposure
• Provide a safe secure setting

23
Drop out rates different CBT models compared

• Different psychological treatments may not differ
  much in symptom reduction
• They do differ significantly in acceptability

24
General points on effectiveness of CBT
(effectiveness v.s. efficacy)

• 67 of those who complete treatment no longer
  meet PTSD criteria
• But pre post symptom scores negatively
  correlated with drop out rates indicating that
  those who dont improve may drop out
• Trials exclude approx. 30 of referrals which is
  lower than for other diagnoses e.g.. Depression
• Combat related PTSD consistently shows poorer
  outcome