Exposure in the Treatment of Posttraumatic Stress Disorder

EXPOSURE IN THE TREATMENT OF POSTTRAUMATIC STRESS DISORDER Johanna Christina Theron Dissertation presented for the degree of Doctor of Psychology at Stellenbosch University Promotor: Prof A.T. Moller Co-Promotor: Prof B.B. Van Heerden December 2007 Stellenbosch University https://scholar.sun.ac.za II DECLARATION I, the undersigned, hereby declare that the work contained in this dissertation is my own original work and that I have not previously in its entirety or in part submitted it at any university for a degree. Signature: Date: ;ioo={- 11 - 01 Copyright © 2007 Stellenbosch University All rights reserved. Stellenbosch University https://scholar.sun.ac.za 111 ABSTRACT A review of the literature revealed that several well-controlled outcome studies found prolonged exposure effective in the treatment of posttraumatic stress disorder (PTSD). However, all these studies were based on either American or British samples. The present study, therefore, investigated the effectiveness of exposure treatment for PTSD in a South African sample of female survivors of sexual violence. Fifteen patients participated in manualized exposure treatment, consisting of nine sessions of 90 minutes each, while 14 patients served as delayed treatment controls. Results showed that prolonged exposure significantly reduced all the PTSD symptom clusters (re-experiencing, avoidance, and arousal) from pretreatment to post-treatment, and that this improvement was maintained at follow up after three months. At the end of treatment no treated patient met the diagnostic criteria for PTSD, as assessed by an independent, blind evaluator by means of the Clinician Administered PTSD Scale. The untreated controls all retained the diagnosis of PTSD. The results also showed a gradual reduction in posttraumatic stress symptoms and the associated symptoms of depression, anxiety and dysfunctional cognitions from sessions two to four, again from four to six, and again from sessions six to eight. In addition, based on four case studies, there were indications that prolonged exposure treatment also facilitated a reduction in regional cerebral blood flow (rCBF) bilaterally in the superior and mid frontal regions, as well as mixed bilateral changes in perfusion in the cerebellum and parieto occipital regions. Stellenbosch University https://scholar.sun.ac.za IV OPSOMMING Uit 'n oorsig van die literatuur blyk dit dat verskeie goed gekontroleerde uitkomsstudies aangetoon het dat langdurige blootstelling 'n effektiewe behandelingsprosedure vir posttraumatiese stresversteuring (PTSV) is. Omdat al hierdie studies egter op Amerikaanse of Britse steekproewe gebaseer was, het die huidige studie ten doel gehad om die effektiwiteit van langdurige blootstelling in 'n Suid-Afrikaanse steekproef van vroulike slagoffers van PTSV as gevolg van seksuele geweld te ondersoek. Vyftien pasiente het deelgeneem aan 'n handleidingsgebaseerde blootstellingsprogram bestaande uit nege sessies van 90 minute elk, terwyl 14 pasiente in 'n vertraagde behandeling kontrolegroep ingesluit is. Die resultate het aangetoon dat langdurige blootstelling al die PTSV simptoomgroepe beduidend van voor tot na behandeling verminder het, en dat hierdie verbetering gehandhaaf is by opvolg drie maande na behandeling. Aan die einde van die behandeling het geen van die behandelde pasiente meer aan die diagnostiese kriteria vir PTSV voldoen nie, terwyl die pasiente in die kontrolegroep alma! die diagnose behou het. Die resultate het ook aangetoon dat daar 'n geleidelike verbetering in posttraumatiese stressimptome sowel as die geassosieerde simptome van depressie, angs en disfunksionele kognisies vanaf sessies twee na vier, weer van vier na ses, en weer vanaf sessies ses na agt plaasgevind het. Hierbenewens het dit ook op grond van vier gevallestudies geblyk dat langdurige blootstelling 'n vermindering in serebrale streekbloedvloei bilateraal in die superior en mid-frontale areas, sowel as gemengde bilaterale veranderinge in perfusie in die serebellum en parieto-oksipitale areas gefasiliteer het. Stellenbosch University https://scholar.sun.ac.za v ACKNOWLEDGEMENTS I would like to express my sincere appreciation to the following persons: e1 Prof A.T. Moller, my promotor, for his excellent guidance and continuous support. • Prof B.B. van Heerden, my co-promotor, for his continuous guidance, interest and support. ci Dr J. Warwick for his assistance with the SPECT scans throughout the study. o Mr H. Steele for his assistance with the statistical analysis. o Dr P.O. Carey for his assistance with the analysis and interpretation of the SPECT results. o The doctors and nursing staff at various community hospitals for their help with the identification of potential participants. o The SAPS for their assistance in identifying potential participants. o The staff from Rape Crisis and Mosa'ik for their support and help in the identification of potential participants. o Dr M.F. Gerber and my colleagues at Stikland Hospital and Tygerberg Hospital for their continuous support and encouragement. o Mrs T. van Greunen for the pre-, post-, and follow-up evaluations of the potential participants. o My mother, Elma, for her time and effort with the typing of the dissertation and for her consistent support and encouragement. o My brother, Jan, for his support and encouragement. g My friends for their interest and support. o My Heavenly Father, without whose strength this dissertation would not have been possible. Stellenbosch University https://scholar.sun.ac.za Vl CONTENTS 1 INTRODUCTION AND OBJECTIVES 1 1.1 POSTTRAUMATIC STRESS DISORDER 1 1.2 PSYCHOLOGICAL TREATMENT OF POSTTRAUMATIC STRESS DISORDER 3 1.3 PROBLEM STATEMENT, OBJECTIVES AND HYPOTHESES 6 1.4 OUTLINE OF DISSERTATION 7 2 POSTTRAUMATIC STRESS DISORDER 8 2.1 DIAGNOSTIC CRITERIA 8 2.2 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS 11 2.3 POSTTRAUMATIC STRESS DISORDER AND COMORBIDITY 13 2.4 COURSE AND PROGNOSIS 15 2.4.1 Risk Factors in the Development of PTSD 16 2.5 IMPACT ON FUNCTIONING AND QUALITY OF LIFE 23 2.6 EPIDEMIOLOGY AND PREVALENCE 25 2.6.1 Trauma Populations 26 2.6.2 Other groups 29 2.7 MEMORY AND POSTTRAUMATIC STRESS DISORDER 31 2.8 POSTTRAUMA TIC STRESS DISORDER IN CULTURAL CONTEXT 38 2.9 NEUROBIOLOGY 47 2.10 NEUROCHEMICAL SYSTEMS 49 2.11 CONCLUSION 54 3 TREATMENT OF POSTTRAUMATIC STRESS DISORDER 56 3.1 INTRODUCTION 56 3.2 OVERVIEW OF PSYCHOLOGICAL TREATMENTS 56 3.2.1 Psychodynamic Therapy 56 3.2.2 Group Therapy 59 3.2.3 Hypnotherapy 63 Stellenbosch University https://scholar.sun.ac.za Vll 3.2.4 Eye Movement Desensitization and Reprocessing 65 3.2.5 Cognitive-behaviour Therapy 68 3.2.5.l Cognitive Therapy and Cognitive Restructuring 68 3.2.5.2 Cognitive Processing Therapy 72 3.2.5.3 Stress Inoculation Training 73 3.2.5.4 Systematic Desensitization 76 3.2.5.5 Exposure Treatment 77 3.2.6 Psychological Debriefing 77 3.3 PHARMACOTHERAPY 82 3.3.l Conceptual basis for medication in PTSD 82 3.3.2 Biological basis for medication in PTSD 83 3.4 CONCLUSION 84 4 EXPOSURE TREATMENT FOR PTSD 86 4.1 COGNITIVE-BEHAVIOURAL THEORIES OF PTSD 86 4.1.1 Rachman's Emotional Processing Theory 87 4.1.2 Ehlers and Clark's Cognitive Theory 88 4.1.3 Brewin, Dalgleish and Joseph's Dual Representation Theory 89 4.1.4 Foa's Emotional Processing Model 90 4.2 EXPOSURE TREATMENT 92 4.2.1 Characteristics of Effective Exposure Treatment 92 4.2.2 Foa's Exposure Treatment for PTSD 94 4.3 RESEARCH ON EXPOSURE TREATMENT FOR PTSD 99 4.3.l Gold Standards 99 4.3.2 Outcome Studies on Exposure Treatment for PTSD 101 4.4 CONCLUSION 107 5 METHOD 109 5.1 PROBLEM STATEMENT, OBJECTIVES AND HYPOTHESES 109 5.2 RESEARCH DESIGN 110 5.3 PARTICIPANTS 112 Stellenbosch University https://scholar.sun.ac.za Vlll 5.3.1 Description of Participants 112 5.3.2 Selection of Participants 114 5.4 MEASURING INSTRUMENTS 115 5.4.1 Structured Interviews 115 5.4.1.1 Clinician Administered PTSD Scale (CAPS) 115 5.4.1.2 Structured Clinical Interview for DSM IV Axix I Disorders (SCID I) 116 5.4.2 Self-report Measures 117 5.4.2.1 Post Traumatic Stress Disorder Symptom Scale - Self Report 117 5.4.2.2 Beck Depression Inventory 118 5.4.2.3 Beck Anxiety Inventory 120 5.4.2.4 Weekly Ideas Questionnaire 120 5.4.3 Single Photon Emission Computed Tomography (SPECT) 121 5.5 PROCEDURE 122 5.6 TREATMENT 127 6 RESULTS 130 6.1 OBJECTIVES AND HYPOTHESES 130 6.2 STA TIS TI CAL ANALYSIS 130 6.3 COMPARISON OF TREATMENT AND CONTROL GROUPS ON SCORES OF THE CLINICIAN ADMINISTERED PTSD SCALE 132 6.4 COMPARISON OF POSTTRAUMATIC SYMPTOMS, DEPRESSION, ANXIETY AND DYSFUNCTIONAL COGNITIONS AT DIFFERENT TIMES OF MEASUREMENT DURING TREATMENT 138 6.5 ANALYSIS OF SPECT IMAGES 144 7 DISCUSSION 152 7.1 INTRODUCTION 152 7.2 EFFECTS OF EXPOSURE TREATMENT ON PTSD SYMPTOMS 153 7.3 EFFECTS OF EXPOSURE TREATMENT ON COMORBID SYMPTOMS ASSOCIATED WITH PTSD 154 7.4 BRAIN METABOLIC CHANGES AFTER EXPOSURE TREATMENT 156 Stellenbosch University https://scholar.sun.ac.za lX 7.5 GENERAL CONCLUSION 160 7.6 LIMITATIONS OF THE PRESENT STUDY 161 7.7 RECOMMENDATIONS FOR FUTURE RESEARCH 164 REFERENCES 166 Stellenbosch University https://scholar.sun.ac.za x LIST OF TABLES Table 1 Means and Standard Deviations for Scores on the Clinician Administered PTSD Scale at Pre-treatment, Post-treatment, and Follow-up for the Treatment Group (n = 15) 132 Table 2 Means and Standard Deviations for Scores on the Clinician Administered PTSD Scale at Pre-treatment and Post-treatment for the Control Group (n = 14) 132 Table 3 Comparison of Treatment (n = 15) and Control Groups (n = 14) on Scores on the Clinician Administered

Load more