Emory Medicine: Strategic ImplementingRepositioning an Early 2013- 2017Intervention for the Prevention of PTSD in Emergency Department Patients

Barbara Olasov Rothbaum, Ph.D., ABPP Paul A. Janssen Chair in Neuropsychopharmacology Director, Trauma and Anxiety Recovery Program Associate Vice Chair of Clinical Research Professor, Department of Psychiatry Emory University School of Medicine Disclosure

This study was supported by National Institute of Mental Health Grant Numbers R34 MH083078 and R01 MH071537, and the Emory Center for Injury Control, Center for Disease Control Grant Number 5R49CE001494 and a NARSAD Distinguished Investigator award to Dr. Rothbaum. The authors report no biomedical financial interests or potential conflicts of interest. Recognition and Description of Posttraumatic Stress Disorder DSM IV to 5 subcategories (4 to 5)

Criteria DSM-IV DSM-5

A Trauma Trauma

B reexperiencing intrusion

C Avoidance and avoidance numbing D hyperarousal Negative alterations in cognitions and mood

E - Marked alterations in arousal and reactivity A Prospective Examination of PTSD in Rape Victims

Percent of Victims with PTS 100 94

80 79 70 64 59 55 60 53 53 45 48 47 41

40 Percent Percent (%) 20

0 1 2 3 4 5 6 7 8 9 10 11 12 Assessment Rothbaum BO et al. J Traumatic Stress. 1992;5(3):463; NIMH Grant No. R01MH42178 Severity of PTSD Symptoms

Non-PTS PTS 30 25 20 15 10 5

0 1 2 3 4 5 6 7 8 9 10 11 12 Assessment

Rothbaum BO et al. J Traumatic Stress. 1992;5(3):464; NIMH Grant No. R01MH42178 Extinction and Habituation

• We view PTSD as a disorder of extinction

McSweeney FK, Swindell S. 2002. Common processes may contribute to extinction and habituation. J Gen Psychol 129:364-400 Evidence from Davis Lab (animals)

Extinction training conducted very shortly after fear conditioning (10 min) seems to prevent all the classic signs of relapse:

– reinstatement – context specificity – spontaneous recovery Opportunity Unlike other psychiatric disorders, the precipitant for adult PTSD is a known event, allowing for immediate intervention, presenting the potential to prevent, and ultimately eliminate for many, the occurrence of this most serious condition. Early Interventions Early Intervention Conclusions

• Early interventions may interfere with natural recovery

• No evidence for which early interventions help

• Need to have right amount of exposure and arousal for optimum response

• Later early interventions (ASD, weeks later) are effective at preventing the development of PTSD (Foa, Bryant) “Effects of Early Psychological Intervention to Prevent PTSD” Study Goals Short-term Goal:

Can exposure therapy in the immediate aftermath of trauma prevent the development of PTSD?

National Institute of Mental Health, Grant No. R34 MH083078

“Effects of Early Psychological Intervention to Prevent PTSD” Study

Intervention Conditions: Randomly assign 134 ER patients to: Immediate Treatment: 3 total PE sessions: #1- in ED, #2-3 delivered 1-2 wks after ED; or Assessment only (4 & 12 wks post-trauma) ED Protocol – Session 1

1) introduction outlining treatment components and rationale (5 min); 2) Prolonged Imaginal Exposure (reliving and retelling the traumatic event narrative and associated cognitions and emotions) (30-45 min); 3) Processing “lite” - identification of positive self- statements to reframe unhelpful cognitions resulting from the trauma (5 min); 4) identification of behavioral in vivo exposures to prevent avoidance of reminders of the trauma (5 min); ED Protocol – Session 1 (cont’d)

5) psychoeducation on normal reactions to trauma and identification of self-care activities for the coming week (5 min); 6) breathing retraining and instruction to use it when the participant feels overwhelmed by negative emotions or has difficulty sleeping (Session 1 only) (10 min) ED Protocol – Sessions 2 & 3

1) Review homework 2) PE focusing on “hot spots” (the most distressing points of the trauma memory) (30 -45 minutes) 3) Processing “lite” - identification of unhelpful thoguhts and more positive self-statements 4) behavioral in vivo exposures and self-care activities for the coming week Intervention Assessment Only PTSD Diagnosis 60.00 * 50.00

40.00

30.00

20.00

10.00

0.00 Week 4 Week 12 * p < .05 Replication of PACAP genotype and PSS at Week 4-12 PTSD, ADCYAP1r1 Genetic Risk, and Intervention 35

30

25

20 assessment-risk

PSSi intervention-risk 15 assessment-resilience intervention-resilience

10

5

0 w4 w12 Week of Assessment P<.05 3-way interaction