Intensive Outpatient Prolonged Exposure for Combat-Related PTSD: A Case Study

The prevalence rates for combat-related posttraumatic stress disorder (PTSD) in U.S. military personnel returning from deployments to Iraq and Afghanistan indicate a significant demand for efficacious treatments that can be delivered in military-relevant formats. According to research with civilian and veteran populations, prolonged exposure is a first-line treatment for PTSD. However, research examining the generalizibility of prolonged exposure to active-duty military service members is scarce. Modifications to the standard prolonged exposure protocol may be required to meet military operational needs and to circumvent unique treatment barriers associated with the military. Intensive outpatient or compressed treatment delivered over a short time period has the potential for significant operational utility for active-duty military populations. Intensive outpatient practice formats have been found to be efficacious for the treatment of other anxiety disorders (i.e., specific phobia, obsessive-compulsive disorder). The present case report is the first to evaluate the use of intensive outpatient prolonged exposure for combat-related PTSD in an active-duty military service member. Treatment consisted of 10 full-day outpatient sessions over a 2-week period. The patient’s PTSD, depression, and anxiety were dramatically reduced by the end of treatment, and she no longer met diagnostic criteria for PTSD. She remained in full remission at the 6-month follow-up.     

Prolonged Exposure Therapy With an Older Adult: An Extended Case Example

Prolonged exposure therapy (PE) has gained strong empirical support for posttraumatic stress disorder (PTSD) in the general population. However, some authors have suggested that exposure therapies may be less effective for the treatment of PTSD in older adults. There is a paucity of empirical treatment studies for older adults with PTSD. The extant studies are briefly reviewed. There are indications that exposure therapies can be feasible, safe, and efficacious for older adults. However, the degree and maintenance of gains may be reduced in older adults relative to younger adults. A case example is presented to provide a detailed illustration of PE conducted with an older adult. The treatment is presented in five phases, including standard treatment components and suggested modifications for older adults. The modifications include careful use of terminology, slowing down the presentation of some information, involvement of family members, and utilizing technology to minimize the negative effects of physical impairments and stigma.     

Intensive Outpatient Program Using Prolonged Exposure for Combat-Related PTSD: A Case Study

Although prolonged exposure (PE) has been identified as a first-line treatment for posttraumatic stress disorder (PTSD), research has found that military service members and veterans have smaller reductions in symptom severity compared to civilians. The nature of trauma in a deployed combat setting and the unique complexities of military culture have been proposed as explanations for greater rates of PTSD and poorer treatment response to first-line psychotherapies in military and veteran populations. This paper presents a case study to highlight how a novel, intensive outpatient program utilizing prolonged exposure therapy (IOP-PE) may benefit military personnel with combat-related PTSD. The patient is a Caucasian man in his early 40s seeking treatment for PTSD after more than 10 years of enlisted, active duty military service across two branches and three combat deployments. The IOP-PE includes the standard PE components and eight, nonstandard treatment augmentations tailored for military personnel. In contrast to standard PE, which typically is delivered weekly over several months, IOP-PE consists of 15 daily, 90-minute PE sessions conducted over 3 weeks. The patient demonstrated large reductions on the Clinician-Administered PTSD Scale (28 points) and PTSD Checklist (48 points) by the 6-month posttreatment follow-up point. Findings provide support for conducting further research that determines whether IOP-PE is effective and tolerable in military and veteran populations.     

Peer-Enhanced Exposure Therapy (PEET): A Case Study Series

Prolonged exposure (PE) therapy is highly effective in reducing symptoms of PTSD, but it is often difficult for veterans to engage in and adhere to all prescribed components of this therapy. This article details a preliminary, feasibility test of Peer Enhanced Exposure Therapy (PEET), a new, manualized intervention allowing specially trained peer specialists who have completed PE to facilitate treatment engagement and adherence during PE by providing individual in-person and telephone support, coordinating peer support services with PE therapists. This case study outlines the theoretical foundations, session content, and both qualitative and quantitative data for two of the first veterans and first peer specialists involved in implementation of PEET. In this case study, the veterans made gains in symptom management expected in PE. Despite the historically high dropout from PE, both veterans completed a full course of PE. There was also evidence of improvement in rehabilitation outcomes, such as community integration, independent living skills, interacting with others, and maintaining friends and activities. Data support the feasibility and acceptability of the intervention; implications for future research are discussed.     

Prolonged Exposure Therapy for PTSD among Individuals in a Residential Substance Use Treatment Program: A Case Series

Clients with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders present a unique challenge for clinicians in substance use treatment settings. Substance dependent individuals with PTSD tend to improve less during substance use treatment and relapse more quickly following abstinence attempts compared to those without PTSD. Recent scientific efforts have focused on understanding the potential benefit of providing PTSD treatment concurrent with substance use treatment. The current case study describes 4 individuals with PTSD in a residential substance use facility who received prolonged exposure therapy for treatment of PTSD, in addition to the substance use treatment. These individuals completed 9 bi-weekly 60-minute sessions of prolonged exposure, as well as in vivo and imaginal exposure homework between sessions. None of the clients met criteria for PTSD at the end of treatment, with these gains being maintained at 3- and 6-months post-treatment. Additionally, the clients did not relapse in response to undergoing exposure therapy. Implications for delivery of PTSD treatment in substance use treatment facilities are discussed.     

Prolonged Exposure Therapy and Irritable Bowel Syndrome: A Case Study Examining the Impact of a Trauma-Focused Treatment on a Physical Condition

Previous research has shown that psychological treatments, particularly those employing cognitive techniques, are particularly effective in the treatment of irritable bowel syndrome (IBS). It is presumed that these psychological interventions are effective at ameliorating the IBS by treating an underlying psychological disorder (often an anxiety disorder), which may be contributing to the autonomic reactivity. This case study examined the change in the physical symptoms of IBS for a patient seeking treatment for rape-related PTSD with comorbid conditions of major depression and panic. At posttreatment, the patient no longer met criteria for PTSD, major depression, or panic. In addition, her primary symptom of IBS, diarrhea frequency, was significantly improved. These findings were maintained at 3 and 9 months posttreatment. Implications for the assessment and treatment of IBS patients with PTSD are discussed.     

Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans With Moral Injury-Based PTSD: Two Case Examples

Moral injury refers to acts of commission or omission that violate individuals’ moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations—thus, morally injurious events are often implicated in the development of posttraumatic stress disorder (PTSD) for military service members and veterans. Although prolonged exposure (PE) and cognitive processing therapy (CPT) have been well established as effective treatments for veterans who are struggling with PTSD, it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this paper is to detail how the underlying theories of PE and CPT can account for moral injury-based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The paper concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.     

Change in sleep symptoms across Cognitive Processing Therapy and Prolonged Exposure: A longitudinal perspective

Sleep disturbance is a core component in posttraumatic stress disorder (PTSD). Although cognitive-behavioral treatments for PTSD reduce the severity of sleep symptoms, they do not lead to complete remission. The present study examines the impact of Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) on subjective measures of sleep disturbance from treatment randomization through long-term follow-up (LTFU). Participants were 171 female rape victims with PTSD who were randomly assigned to CPT, PE, or Minimal Attention (MA). After 6-weeks, the MA group was randomized to CPT or PE. Sleep symptoms were assessed at baseline, post-MA, post-treatment, 3-months, 9-months and LTFU using the Pittsburgh Sleep Quality Index (PSQI) and nightmare and insomnia items from the Clinician Administered PTSD Scale. Change in sleep during MA, from pre- to post-treatment for CPT and PE, and from post-treatment through LTFU was assessed using piecewise hierarchical linear modeling with the intent-to-treat sample. Controlling for medication, sleep improved during CPT and PE compared to MA, and treatment gains were maintained through LTFU. CPT and PE were equally efficacious and improvements persist over LTFU, yet, neither produced remission of sleep disturbance. Overall, sleep symptoms do not remit and may warrant sleep-specific treatments.     

Perceived Perpetration During Traumatic Events: Clinical Suggestions From Experts in Prolonged Exposure Therapy

Prolonged exposure therapy (PE) is a treatment that has proven effectiveness in reducing the symptoms of posttraumatic stress disorder (PTSD) and related psychopathology. Providing PE to trauma survivors with PTSD, particularly related to combat trauma, often involves addressing guilt or shame related to their contextually appropriate use of violence and lethal force. In this paper, we present 4 clinical case vignettes in order to define the concept of perceived perpetration, and offer clinical suggestions for assessment and treatment with PE. Specifically, we examined issues such as identifying what type of traumatic events are appropriate for the use of PE, how to approach issues surrounding actions that could be perceived as perpetration, and attending to trauma-related guilt or shame.     

Brief Cognitive Behavioral Family Therapy Following a Child's Coming Out: A Case Report

Few interventions have been proposed for the treatment of families following a child's disclosure of nonheterosexuality. To address this gap in the literature, the current paper outlines a brief cognitive behavioral family treatment (CBFT) for families negotiating the coming-out process and illustrates this approach with a case example. Parents' attributions, beliefs, and expectations are explored and challenged. The family is exposed to increasingly salient topics and directed to increase the frequency of positive family experiences. Lastly, the family is taught specific listening and problem-solving skills to bolster adaptive family communication. This paper is among the first to apply an empirically supported therapeutic framework to support family adjustment following a child's disclosure of sexual orientation. The potential usefulness and limitations of this CBFT application are discussed.     

Written Exposure Therapy for Suicide in a Psychiatric Inpatient Unit: A Case Series

Patients with posttraumatic stress disorder (PTSD) are at an elevated risk of suicide. For patients hospitalized for suicide risk, psychosocial treatment and stabilization are routinely offered; however, the availability of evidence-based, manualized therapeutic interventions for PTSD is sparse. Typically, the short duration of hospitalization makes it difficult to accommodate evidence-based, trauma-focused treatments. This article presents the clinical course of four active-duty service members with PTSD who were hospitalized in a psychiatric inpatient unit for acute suicide risk and treated with Written Exposure Therapy for Suicide (WET-S). WET-S is a brief, five-session therapy based upon Written Exposure Therapy and augmented with Crisis Response Planning for Suicide Prevention. Both posttraumatic stress symptoms and suicidal ideation were reduced from pre- to posttreatment for three of the four patients treated. WET-S shows promise as a manualized therapeutic intervention that can be delivered on an inpatient psychiatric unit.     

Cognitive Behavior Therapy With Body Image Exposure for Bulimia Nervosa: A Case Example

Cognitive behavior therapy (CBT) is an effective treatment for bulimia nervosa (BN). However, among patients with BN, symptom improvement is more pronounced for behavioral eating symptoms (i.e., bingeing and purging) than for body image disturbance, and the persistence of body image disturbance is associated with relapse. The need for more effective body image interventions led to the development of mirror exposure, which focuses on encouraging patients to view themselves in a holistic, nonjudgmental, mindful fashion. Behavioral manifestations of body image disturbance—body checking and avoidance—are also targeted in order to reduce and eliminate such behaviors and their associated preoccupation and distress. A preliminary trial of Body Image Exposure has shown promise, but it has not yet been tested in the context of CBT for BN. The case of “Sara” illustrates the application of this targeted treatment for body image disturbance. Central clinical issues around the perceptual, cognitive, and behavioral components of body image are delineated as they arose in treatment, as are issues of motivation and compliance. Treatment was associated with improvement in eating symptoms, body image, and mood.     

Prolonged Exposure Therapy for a Vietnam Veteran With PTSD and Early-Stage Dementia

Although prolonged exposure therapy (PE) is considered an evidence-based treatment for PTSD, there has been little published about the use of this treatment for older adults with comorbid early-stage dementia. As the number of older adults in the United States continues to grow, so will their unique mental health needs. The present article describes the successful coordination of care and application of PE in the assessment and treatment of a Vietnam veteran with comorbid PTSD and early-stage dementia. Measures related to the patient's cognitive and psychological functioning were obtained before, during, and after treatment. PE was associated with significant declines in PTSD and depression symptoms. Moreover, the patient's cognitive functioning was made clearer in the absence of severe psychiatric symptoms. Factors contributing to the patient's positive response are discussed.     

Dialectical Behavior Therapy With Prolonged Exposure for Adolescents: Rationale and Review of the Research

Among adolescents, interpersonal trauma has been associated with severe post-traumatic stress disorder (PTSD) and impairments across multiple domains of functioning (e.g., Derosa, Amaya-Jackson & Layne, 2013; Ford, Courtois, Steele, van der Hart, & Nijenhuis, 2005; van der Kolk, 2005). Such difficulties can include high-risk behaviors such as active suicidality (Middlebrooks & Audage, 2008) and nonsuicidal self-injurious behavior (NSSI; Hu, Taylor, Li, & Glauert, 2017). While there have been many advances in the treatment of trauma, treatment dropout for adolescents seeking trauma-informed treatment is predicted by diagnostic comorbidity and complexity (Sprang et al., 2013), as well as the number of traumatic events endorsed (Wamser-Nanney & Steinzor, 2016). Many traumatized adolescents with high-risk behaviors are referred to Dialectical Behavior Therapy (DBT-A). However, DBT-A does not yet include a specific, evidence-based protocol for treating PTSD, without which treatment gains may not be sustained for traumatized adolescents (Harned, Korslund, & Linehan, 2014). While Prolonged Exposure (PE) is indicated as the gold-standard treatment for PTSD and has proven effective for adolescents (PE-A; Foa, McLean, Capaldi, & Rosenfield, 2013), it has not yet been validated with adolescents who are actively suicidal. However, PE has successfully been integrated within DBT for adults with co-occurring Borderline Personality Disorder and PTSD (e.g., DBT-PE; Harned et al., 2014). Based upon this model, the current paper proposes the integration of DBT-A and PE-A to treat adolescents with interpersonal trauma who also present with high-risk behaviors. The paper discusses anticipated complications related to adapting this model for adolescents and provides direction for future research.     

Exposure Therapy for Posttraumatic Stress Disorder: A Meta-Analysis

This meta-analysis compares the findings of empirical studies that employ either a traditional form of cognitive–behavioral-based exposure therapy or virtual reality exposure therapy (VRET) for the treatment of posttraumatic stress disorder (PTSD) to determine which is more viable and effective. Statistical analyses were performed on 26 studies to determine pre- to posttreatment effect sizes and interactions. Results demonstrated a trend toward significance in favor of traditional exposure therapy showing lower posttreatment PTSD. Limitations included a restricted number of relevant studies; future research on VRET for PTSD should orient more to experimental designs, larger samples, and increased use of control groups.     

Examining Cognitive Functioning Following TASER Exposure: A Randomized Controlled Trial

Individuals who experience electrical injury suffer significant, sometimes long‐term deficits in neuropsychological functioning. The TASER, an electrical device used by thousands of police departments, generates a high‐voltage (up to 50 000 V), low‐amperage (2.1 mA) current of electricity that is designed to disable a resistive criminal suspect. Questions have emerged regarding the potential for TASER exposure to cause impairment in cognitive functioning. In the current study, healthy human volunteers were randomly assigned to four groups, two of which received a TASER exposure. Participants completed a battery of cognitive tests before and after receiving their assigned treatment. Participants who received a TASER exposure experienced statistically meaningful declines in measures of verbal learning and memory, although deficits lasted less than 1 hour. After TASER exposure, participants also self‐reported significant difficulties with concentration, anxiety, and feeling overwhelmed. Other dimensions of cognitive functioning were not affected. Our findings show that the effects of TASER exposure on brain functioning are not well understood. Copyright © 2015 John Wiley & Sons, Ltd.