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References

Rauch, S. A. M., & Rothbaum, B. O. (2016). Innovations in exposure therapy for PTSD treatment. Practice

Innovations, 1(3), 189–196. https://doi-org.library.capella.edu/10.1037/pri0000027

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Innovations in Exposure Therapy for PTSD Treatment

By: Sheila A. M. Rauch

Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, and

Atlanta VA Medical Center, Atlanta, Georgia;

Barbara O. Rothbaum

Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine

Acknowledgement:

In both Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-

TR) and DSM–5, posttraumatic stress disorder (PTSD) is characterized by intrusive memories and

avoidance of reminders (American Psychiatric Association, 2000, 2013). No other DSM anxiety

diagnosis has a specific onset event. Fear and anxiety are a normal response to trauma. For the

majority of individuals exposed to a traumatic event, this fear and anxiety naturally extinguishes over

time. For a significant minority, fear does not extinguish naturally over time and can develop into

chronic PTSD. Therefore, PTSD can be conceptualized as a disorder of extinction. Processes

involved in learning, especially extinction learning and retention, are central in PTSD and may hold

the keys to improved treatments. Converging evidence supports that although extinction is not the

only process at work, it is one key process involved in the development and maintenance of PTSD

(Rauch & Liberzon, 2016), making translational neuroscience especially relevant.

Recent treatment guidelines and meta-analyses support that trauma focused treatments, including

prolonged exposure therapy, have the highest level of support for efficacy and effectiveness (IOM,

2014). SSRIs have also been supported as a first line treatment in the 2010 VA/DOD Clinical

Practice Guidelines, although other reviews have not supported their efficacy (IOM, 2014; VA/DOD,

2010). Even with these effective treatments, most people with PTSD never receive effective

interventions. Many factors contribute to people suffering with PTSD not receiving effective PTSD

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treatment, including access and stigma. Hoge and colleagues (Hoge et al., 2004) reported that only

23% to 40% of service members reporting mental health difficulties (including PTSD and/or

depression) in the past year had sought any care. Even if they seek care, access to effective

interventions is low. Indeed, few providers receive training in evidence-based psychotherapy to

provide these interventions. Furthermore, rates of drop and partial response to effective treatments

are high, ranging from 20% to even above 50% (Bradley, Greene, Russ, Dutra, & Westen, 2005). As

such, improving access, acceptability, speed of response, and efficacy through modifications to

current treatments or development of new interventions is critical. As increasing numbers of veterans

return from the current conflicts in the Middle East, the burden of PTSD promises to increase for the

foreseeable future (IOM, 2014). Providing effective intervention for those returnees suffering from

PTSD is a necessary societal response.

Why Innovate?

It is important to have choices in the treatment for PTSD. Mounting evidence suggests that there may

be several subtypes of PTSD. Each subtype is likely to be shown in neuroscience informed studies to

respond to different treatments. In addition, patients with PTSD tend to be so avoidant by the nature

of the disorder, it is important to have treatment choices. Indeed, even if head to head comparisons

did not show the superiority of one treatment modality over another, if a patient will not engage in a

certain treatment, it doesn’t matter if it’s more efficacious. In this way, acceptability is one reason to

innovate PTSD treatment. The more choices for efficacious treatments we can present, the more

likely our PTSD patients will find one acceptable to them and complete a full course of treatment.

Continuous improvement of clinical care and outcomes is always the goal of medical science. Within

PTSD treatment, innovations may focus on improving access and overcoming barriers to effective

interventions as well as improving efficacy. Innovations may include entirely novel interventions,

augmentation of new strategies to known effective interventions, or modification of known effective

interventions to increase retention, speed of response, or overall impact. As noted above, several

effective interventions are available for the treatment of PTSD, but partial response, relapse, and

dropout are significant issues in all treatments identified thus far. Furthermore, most patients with

PTSD never seek treatment, and, even if and when they do seek treatment, cannot access these

proven interventions. Thus, innovations in all of the areas mentioned are critical.

Exciting work on innovations is underway with PTSD experts and others coming from all areas of

neuroscience and technology to bridge the gap. We will present some of the most promising

innovations in PTSD treatment through application of innovations with clinical case examples. These

case examples are partially based on real patients with additional information added and no

identifying information included, to protect privacy.

Case 1 Description

Mr. X is a 29-year-old combat veteran who completed two deployments to Iraq during his 7 years as

an enlisted infantryman in the U.S. Army. He is currently married although separated and has 2

young children who reside with his wife. He experienced many traumatic incidents during his

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deployments including exposure to blasts from improvised explosive devices, hand to hand combat,

and firefights. However, the trauma that haunts him was when a fellow soldier sexually assaulted him

in the shower at the end of his second deployment. Such interpersonal traumas often occur with

shame and betrayal that can add to difficulties in disclosure of the event. After returning home, he

engaged in heavy drinking that resulted in his eventual discharge. Although his discharge was

honorable, his rank was reduced and he was considerably angry about the discharge process. He

never disclosed the incident because of guilt and shame. His drinking worsened after his discharge,

and he was eventually hospitalized when he told his wife that he was going to “blow my head off.” Mr.

X has been sober for 2 months since his discharge from the VA inpatient substance abuse treatment

program. He is invested in his sobriety but worries that he may drink under stress. He disclosed his

military sexual experience while in the inpatient program and reported significant PTSD symptoms

that contribute to his urge to drink. Mr. X lives more than 2 hours from the nearest VA facility and

remains very concerned with mental health labels and how they may impact his reputation and the

potential divorce and custody proceedings.

Case 2 Description

Ms. D is now 30 years old and has PTSD following a sexual assault at age 25. At the time of the

incident, she was working at a local newspaper as a writer in a job that she had dreamed of since

high school. During the hiring process, she met several colleagues who were very friendly and one

who had been very helpful in showing her the office procedures and providing her help as she

started. They started dating and on their second date she invited him to her apartment for dinner. He

raped her. He told her that if she told anyone he would make sure she was fired from work. He was

verbally abusive, saying that she was only hired so he could have her. He physically assaulted her

during the rape. In the days following the incident, she could not get out of bed and called in sick to

work. She blamed herself for letting him come to her home and did not want to tell anyone about

what had happened. When she arrived at work, several of her male colleagues made inappropriate

comments to her suggesting that they knew about what had happened and that her rapist had

already been speaking badly about her and suggesting she was mentally unstable. As the

harassment got worse, she became very depressed and finally decided to quit her job. Over the next

year she withdrew socially from friends and completely quit dating. She was unable to find new work

as she felt more and more as though her rapist had orchestrated her hire in order to rape her. She

moved back in with her parents and filed for disability for depression.

Improving Access and Overcoming Barriers

One hallmark of PTSD is avoidance. As a result, most people suffering with PTSD do not seek

treatment, and those that do seek treatment most often come after many years of suffering with the

symptoms, an average of 9 years post target trauma in one large PTSD treatment study (Foa et al.,

2005). Sociodemographic factors, stigma, and thoughts of hopelessness contribute to these low

rates of help seeking in PTSD (Hoge et al., 2004; Sripada, Pfeiffer, Rauch, & Bohnert, 2015). As

noted in the case example, Mr. X was not willing to disclose the event despite significant negative

consequences, including job loss and relationship loss. Ms. D had not sought any treatment after

more than 5 years. Although all mental health providers want to minimize stigma, these concerns in

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our patients still reflect realistic consequences in our environment. As such, working on ways to meet

our patients where they are and minimize labels and potential negative consequences is important.

In addition to overcoming patient avoidance of treatment, once patients with PTSD finally seek care,

access to well-trained providers of the first-line psychotherapeutic treatments for PTSD is limited. As

noted above, although medications are often available through primary care or other mental health

prescribers, for those people with PTSD who do not want medication, do not fully respond, or have

side effects, access to psychotherapy for PTSD with proven efficacy is limited. Availability of trained

providers significantly impacts access to effective PTSD care. Even when providers have been

trained in evidence-based interventions, very often they do not deliver them with fidelity (IOM, 2014).

There are numerous organizations devoted to training more clinicians in evidence based treatments

for PTSD, especially for military service members and veterans, for example, the Center for

Deployment Psychology (http://deploymentpsych.org/) and the Star behavioral training program

(http://starproviders.org/providers/states/indiana/welcome-page-id-1). As a twist on how to most

efficiently utilize trained providers and assist in integration of PE into standard practice, a small

sample study recently examined whether PE maintains efficacy in 60 min sessions compared to 90

min sessions, finding encouraging results that shorter sessions may be effective (Nacasch et al.,

2015). However, larger studies and replication are needed to firmly support a standard change to 60

min sessions in PE.

Innovation has also expanded into using PE with many comorbid populations. Indeed, research

supports the use of integrated exposure based PTSD and SUD protocols, including the Concurrent

Treatment of PTSD and Substance Use Disorders with PE (COPE) protocol (Foa et al., 2013; Mills et

al., 2012). Such expansions into these complex populations offers patients renewed hope for new

treatment options that may assist in their recovery. Work with psychotic and highly dissociative

patients has also supported the use of PE as effective (Grubaugh et al., 2016; Hagenaars, van

Minnen, & Hoogduin, 2010; van den Berg et al., 2015). As such, many studies have extended PE

treatment to many of the groups that had previously been excluded from treatment studies with

exposure therapy for PTSD, with excellent results even in these complex populations.

As one way to increase the reach of effective psychotherapies, many PTSD treatment developers

and researchers have been working on ways to bring the effective elements of PTSD focused

psychotherapy to places where these patients are. Very creative versions of effective interventions

for use through Web based and self-help bibliotherapy programs are in various stages of

development (Cigrang et al., 2011, 2015; Sloan, Lee, Litwack, Sawyer, & Marx, 2013). In Written

Exposure Therapy (WET), patients attend sessions where they write out their target trauma narrative

and review theses narratives with their therapist. These are one on one sessions, but the majority of

the session has the patient writing without the therapist present in the room. Thus, there may be

efficiency in therapist time required, although the barriers of physical presence in the clinic and one

on one format remain (Sloan et al., 2013). Data support that WET shows significant reductions in

PTSD symptom severity (Sloan et al., 2013). Web based versions of PE are under development in

order to overcome the barrier of physical presence in the clinic for effective care (McLean, personal

communication). Data regarding efficacy of Web based PE is not yet available, but other adaptations

of CBT for PTSD programs have promising results (Engel et al., 2015; Gersons, Meewisse, &

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Nijdam, 2015).

An alternate way to improve reach involves moving specialty mental health expertise into primary

care. In an effort to reach patients with PTSD where they are, a modification of PE for use in a brief

primary care mental health format was created, with excellent pilot data supporting its efficacy

(Cigrang et al., 2015). Indeed, 52% of patients did not meet criteria for PTSD at one month following

the 4 30-min sessions, and the gains were maintained over one year of follow-up. In addition, in

order to take advantage of the PE and CPT training initiatives in VA and DOD, the PE-PC developers

created the model such that people who completed provider training in either PE or CPT could pick

up the manuals and use the new model with phone consultation of 2 cases. Thus, the model is

designed to meet the patients where they are (primary care) and allow for easy dissemination to

providers in primary care mental health with minimal additional training.

For Mr.X, during his next primary care visit after discharge from substance use treatment, his primary

care provider checks in on his status. Mr. X discloses significant sleep difficulties, and this triggers

the provider to ask about his experiences during deployment in combat and otherwise. Mr. X

discloses that he experienced military sexual trauma during his second deployment. Although the

provider is surprised to hear this disclosure, he is able to immediately connect Mr. X with the

colocated VA Primary Care Mental Health Provider, who conducts a brief assessment and is then

able to discuss treatment options, including medications in primary care, PE-PC, or referral to

specialty mental health. Mr. X decides that he does not want medication and prefers to stay in

primary care for treatment. They start PE-PC the next week. This quick start in the setting of the

patient’s choice helps to take advantage of a brief window of opportunity when MR. X was willing to

approach his trauma with treatment.

Indeed, as all of these modifications of effective programs are developed, one can envision a true

stepped care model of PTSD treatment that provides the right intervention to the right patient at the

right dose at the right time. Although the case example of MR. X would suggest a level of severity

that would warrant a jump to specialty mental health if possible, many times patients will not take

those referrals or do not follow through on showing up for weekly sessions. As such, starting with a

patient directed bibliotherapy or Web based version of an effective intervention, such as PE, may

provide the necessary dose. Once Mr. X begins that program, if he decides that he needs a higher

level of care or if he has issues that exceed the resources of the bibliotherapy or Web based

program, he can move to the next step and receive a psychotherapeutic or medication intervention in

primary care. Similarly, if the PC intervention resources do not fully address his needs, he can move

to a specialty mental health setting for weekly intervention. Finally, intensive outpatient programs

may be necessary. This model would provide efficiency in use of expertise of providers, flexibility for

patient choice and preference, and economic efficiency as providing the minimum necessary dose of

care to reach criterion. We are not close to a system that can implement this full model yet, but are

developing the pieces that may make it happen.

Additional innovations in mode of therapy provision can also support access to care for PTSD. These

advances include the use of telemental health that can allow providers with specialized training in

PTSD to provide effective interventions into remote communities and even into the homes of patients

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far flung from medical facilities. VHA has excellent models of telelmental health that are working

across the country, but variations in laws and payment for telemental health continue to be significant

barriers outside of federal facilities (Tuerk & Shore, 2015).

Improving Efficacy

Critical innovations in PTSD care include efforts to improve efficacy among those who access care.

Within prolonged exposure therapy and other trauma-focused interventions, engagement with the

trauma memory and associated emotional and stimulus cues is necessary for patients to experience

benefits. This is often a challenge in avoidant and emotionally distant PTSD patients. Therefore,

many innovations focus on how to increase emotional engagement with the trauma memory and

associated cues. Some of these innovations work to present the trauma memory and cues in ways

that increase immersion in an effort to overcome avoidance, such as virtual reality exposure

programs.

Virtual reality exposure therapy (VRE) asks patients to confront the memory of their most traumatic

events but immersed in a virtual environment. VRE has been used successfully to treat several

anxiety disorders including the fear of heights, the fear of flying, and the fear of public speaking

(Cukor et al., 2015). There are a number of case studies and controlled studies using VRE to treat

PTSD and both military and civilian populations (Rothbaum et al. 2014; Rothbaum, Rizzo, & Difede,

2010). In VRE, patients wear a head mounted display that consists of two little screens, one in front

of each eye, earphones, and a position tracker that changes the view in real time with head

movement. Very often they are sitting on a raised platform that includes a bass shaker so they can

feel the vibrations of, for example, the virtual Humvee. For many environments they also hold a

joystick that allows them to manipulate the environment, for example to drive the virtual Humvee.

Thus, in VRE the patient is recounting the memory while seeing the visuals, hearing the sounds,

feeling vibrations, and smelling salient odors that combine to create a very potent exposure. VRE

may be particularly useful for PTSD patients who are particularly avoidant, as it is more difficult to

avoid such potent stimuli, but that is an empirical question that awaits data. A multisite trial is

currently underway comparing PE to VRE in post 9/11 veterans, combined with a cognitive enhancer

or placebo that should help answer this question (clinicaltrials.gov NCT01352637). The cognitive

enhancer being tested is D-cycloserine (DCS).

To use Mr. X as an example, if he were referred for VRE, we would have our choice of which virtual

environments to use for his exposure therapy. The new BraveMind software has 14 different

environments including an Iraq city market, Humvees driving down desert roads in surroundings that

resemble Afghanistan or Iraq, a forward operating base, and a village, among others. At Emory, we

are testing a new virtual environment for military sexual trauma that includes a motel room, an

apartment, a vehicle, outside an American bar and dark alley, a military base office, a barracks, and

a latrine. Given the fact that Mr. X was raped in the shower while deployed, it is likely that the latrine

environment would match his memory the best. VRE would proceed almost exactly like PE, except

instead of Mr. X’s eyes being closed imagining the attack, his eyes would be open and he would be

viewing the latrine. Everything else would proceed almost exactly as in PE. with multiple accountings

of the traumatic event in the present tense per session and progressing up to hotspots in subsequent

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sessions. Sessions would be audio recorded, likely using the app PE Coach, for Mr. X to practice

imaginal exposure for homework. Following the exposure, Mr. X removes the head mounted display,

and the therapist and Mr. X would engage in emotional processing of the material that emerged

during the exposure.

Other innovations to improve efficacy focus on mechanisms that impact cognitive processes involved

in extinction learning such as yohimbine, DCS, or 3,4-methylenedioxy-methamphetamine. As one

example, DCS is an N-methyl-D-aspartate (NMDA) glutamate receptor partial agonist shown to

facilitate the extinction of fear in exposure therapy when administered immediately prior to treatment

for several anxiety disorders, but not in all trials (Rothbaum et al., 2014). If Mr. X had received DCS

combined with exposure therapy, he would have received a pill about 30 min prior to starting his

exposure therapy session. In our clinical trial comparing DCS to placebo combined with VRE,

patients received an abbreviated course of therapy to allow the DCS to facilitate exposure. Although

a typical course of PE or VRE is 9 to 12 sessions, we delivered six sessions total in this study,

including five of VRE where the patient received a pill. DCS was well tolerated with essentially no

notable side effects, so Mr. X would not likely experience any effects of the pill alone. Although this

study did not find a direct effect of the DCS on PTSD symptoms, we did find an effect for the patients

with more emotional learning in sessions. Thus, if Mr. X received DCS in session and experienced

reduction in distress in session, he would be expected to have more reduction in symptoms than

someone who did not have DCS (Rothbaum et al. 2014).

As mentioned above, PTSD is the only anxiety disorder that includes an external event (i.e., the

traumatic event). This known event presents the opportunity to intervene. Clinically, we hear of

events that occurred immediately posttrauma that have helped survivors in their recovery, such as

supportive family members, or that have interfered with recovery, such as a blaming police officer. On

the basis of these observations, clinical wisdom is that we have until patients sleep to modify the

trauma memory. Basic research with animals found that extinction training delivered immediately

after the fear conditioning erased all indices of conditioned fear.

We have been testing an immediate early intervention aiming to prevent the development of chronic

PTSD. The early intervention is an adaptation of PE abbreviated to be delivered in the emergency

room after patients have been medically cleared to participate. Treatment consists of imaginal

exposure to the trauma memory, abbreviated emotional processing identifying “unhelpful thoughts,”

identifying in vivo exposures to counteract potential avoidance, brief breathing retraining to use at

times that imaginal exposure is not appropriate, such as going to sleep or in the shower, and

instruction in self-care. The first session is delivered in the emergency room, followed by two

additional sessions delivered one week after the first then again a week later. We tape-record the

patient’s recounting for them to listen to for homework and instruct them to practice imaginal

exposure daily. In the first study comparing three sessions of this early intervention to assessment

only, patients who received the early intervention had one half the rate of chronic PTSD, and it

seemed to mitigate a genetic risk of PTSD (Rothbaum et al., 2014).

If this innovative treatment was available to Ms. D, it does require that she would have disclosed it

after the rape occurred. If so, and there was a provider trained in its delivery, she would have been

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asked to recount the details of the assault repeatedly immediately after it occurred. The provider

would tape-record Ms. D’s recounting for her to listen to for homework and ask her to listen to it daily.

As soon as Ms. D opens her eyes following the imaginal exposure, the provider and Ms. D would

emotionally process material that emerged during the imaginal exposure. The therapist asks Ms. D to

write down some more helpful thoughts. Such thoughts might include “It wasn’t my fault; I did nothing

to deserve this assault;” “I can handle the memory and the way to make it easier it to think about it

therapeutically rather than avoid it;” “This is an act of aggression and says nothing about my

competence.” The therapist teaches Ms. D a breathing relaxation technique to use at times that

exposure is not appropriate, such as going to sleep and in the shower, and records it for ease of

practice. She is asked to practice the breathing at least once daily. Self-care activities would be

identified, and in vivo exposures would be listed to counteract Ms. D’s tendency to avoid. Ms. D

would be advised not to cope with alcohol, with an explanation of what it means to emotionally

process this event. They would also briefly discuss potential positive coping, such as being with other

people, doing activities you enjoy, exercising, connecting with your spiritual beliefs, and so forth If this

intervention had been available and delivered, there is a chance Ms. D would not have developed

chronic PTSD and depression, would have been able to disclose the assault to appropriate support

persons, and might have quit her dream job.

Conclusion

As we learn more about how effective PTSD treatments work, we are able to bring this new

knowledge to bear on ways to improve both efficacy and access to effective interventions. Although

we focused on exposure therapy, other new interventions and innovations in other evidence based

psychotherapies are also underway to move the field of PTSD treatment forward. We can bring what

works to where patients are, and we can make each session more efficient and effective. In addition,

as we continue to learn more about PTSD itself, we will be able to identify patients who may respond

better or worse to given intervention options and be able to actually match patients to treatment plans

much more confidently. We have reviewed new methods of implementation of known effective

interventions, such as prolonged exposure therapy, using technology to improving access by creating

brief versions available in settings outside of specialty mental health. Technology has also been used

to enhance engagement in therapy through virtual reality. Finally, we examined neuroscience

informed ways to augment extinction learning and retention to enhance efficacy through various

psychopharmacological interventions. The last 5 years have shown an explosion of knowledge about

extinction and learning processes involved in PTSD, and the next 5 years promise to build on this

knowledge and its application to treatment improvement and innovation. Technology and

neuroscience will continue to guide the future of PTSD care.

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Submitted: March 26, 2016 Revised: June 6, 2016 Accepted: June 7, 2016

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Source: Practice Innovations. Vol. 1. (3), Sep, 2016 pp. 189-196)

Accession Number: 2016-36403-001

Digital Object Identifier: 10.1037/pri0000027

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