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Review
McLean & Foa
11
Review The use of prolonged exposure therapy
to help patients with post-traumatic stress
disorder
Clin. Pract. ,1
Practice Points Carmen P McLean*
1
& Edna B Foa
1
The burden of post-traumatic stress disorder Department of Psychiatry, University
• Post-traumatic stress disorder (PTSD) is often a chronic, disabling condition that is of Pennsylvania, 3535 Market Street,
frequently comorbid with other psychiatric disorders. 6th Floor, Philadelphia, PA 19104, USA
Comorbidity in PTSD *Author for correspondence:
• The presence of PTSD comorbidity challenges differential diagnosis and treatment Tel.: +1 215 746 3327
planning. Fax: +1 215 746 3311
Overview of evidence-based treatments for PTSD mcleanca@mail.med.upenn.edu
• Cognitive-behavior therapy, and in particular exposure therapy, has been found effective
in reducing PTSD severity relative to waitlist and active control conditions.
Description of prolonged exposure therapy for PTSD
• Prolonged exposure (PE) is a specific exposure therapy program that has been extensively
researched and is considered a first-line evidence-based treatment for PTSD.
Does PE work for comorbid populations?
• PE is efficacious for PTSD sufferers with comorbid disorders including depression,
substance dependence, traumatic brain injury and borderline personality disorder.
• In addition to reducing PTSD, PE significantly ameliorates associated symptoms, such as
depression, anxiety and anger.
10.2217/CPR.13.96 Post-traumatic stress disorder (PTSD) is a chronic psychiatric disorder character ized
by intrusive re-experiencing symptoms, avoidance behaviors, elevated arousal, and
changes in cognition and mood. Nearly all individuals with PTSD suffer from at least
one additional psychiatric diagnosis. Prolonged exposure is one of several evidence-
based treatments for PTSD that has been efficacious for PTSD sufferers with a range of
2 comorbid disorders. In this review, we first discuss the prevalence of PTSD comorbidity
and the challenges that it presents to clinicians working with traumatized patients.
We then discuss the treatment of PTSD, focusing on prolonged exposure therapy.
After providing a brief overview of PE, we review evidence supporting the use of PE
2014 in reducing PTSD severity and associated symptoms in a variety of comorbid samples.
Keywords: comorbidity • evidence-based treatment • post-traumatic stress disorder
• prolonged exposure therapy • trauma
The burden of PTSD during their lifetime [1], and certain types of
Post-traumatic stress disorder (PTSD) is a traumas are more likely to lead to PTSD than
chronic and disabling disorder characterized others. For example, 14% of military person-
by intrusive re-experiencing symptoms, avoid- nel deployed to Operations Iraqi Freedom
ance behaviors, elevated arousal, and changes and Operation Enduring Freedom [2] and
in cognition and mood. PTSD affects an approximately 40% of women exposed to sex-
estimated 3.4% of men and 8.5% of women ual assault [3] met criteria for PTSD. Because part of
10.2217/CPR.13.96 © 2014 Future Medicine Ltd Clin. Pract. (2014) 11(2), 233–241 ISSN 2044-9038 231
Review McLean & Foa
PTSD is comprised of a large range of symptoms, it can symptom constellations. This, combined with the fact
cause dysfunction across multiple areas. Without effec- that individuals are often reluctant to volunteer infor-
tive treatment, after 1 year PTSD typically becomes mation about traumatic experiences, increases the risk
chronic, debilitating, and associated with significant that a PTSD diagnosis is missed. Since an accurate
distress and overall functional impairment [4]. More- diagnosis of PTSD is necessary to ensure an appropri-
over, most individuals with PTSD suffer from at least ate treatment program is initiated that will help the
one additional psychiatric diagnosis [5]. For example, patient overcome the disorder, it important that cli-
major depressive disorder (MDD), anxiety disorders nicians conduct a thorough assessment that includes
and substance use disorders all frequently co-occur with screening for traumatic events.
PTSD. This high prevalence of comorbidity greatly In addition to making differential diagnosis more
impacts both the clinical presentation and treatment of challenging, PTSD comorbidity may complicate treat-
PTSD. Therefore, in order to help patients overcome ment. PTSD comorbidity is associated with more
PTSD, it is imperative that treatment addresses the severe clinical impairment, lower quality of life [13–15]
high level of comorbidity seen in this population. and poorer treatment prognosis [16–18]. Although a large
number of studies find that certain psychosocial treat-
Comorbidity in PTSD ments are efficacious in reducing PTSD severity, fewer
As noted above, comorbidity of PTSD with other psy- studies have examined the effect of treatment on comor-
chiatric disorders is the rule rather than the exception. bid conditions. Clinicians should select treatments that
Epidemiological studies have found that 59% of men demonstrated efficacy in ameliorating PTSD among
and 44% of women with PTSD meet criteria for at diverse populations, including those with comorbid
least three psychiatric disorders [5]. In a study of com- conditions. Ideally, clinicians would implement treat-
munity outpatients, PTSD showed a more severe and ments that reduce the symptoms of PTSD as well as
diverse pattern of comorbidity than any other anxi- symptoms of commonly comorbid conditions.
ety or mood disorder [6]. One of the most frequently
comorbid disorders associated with PTSD is MDD. Overview of evidence-based treatments for
Between 48% and 77% of all PTSD sufferers also PTSD
meet criteria for MDD [5–6]. PTSD often co-occurs Cognitive–behavior therapy (CBT) refers to a fam-
with substance use disorders, with rates of PTSD esti- ily of treatment approaches and includes exposure
mated to be at least twice as high among individuals therapy, cognitive therapy and anxiety management.
with alcohol dependence compared with the general CBT has been deemed the treatment approach of
population [7]. Other anxiety disorders, particularly choice in clinical practice guidelines for PTSD [19–22].
generalized anxiety disorder (GAD), are also highly Several CBTs for PTSD have received empirical sup-
prevalent among individuals with PTSD [6]. In addi- port, including prolonged exposure (PE) [23], cognitive
tion, PTSD is associated with elevated rates of physical processing therapy (CPT) [24], cognitive therapy [25]
health problems, including circulatory, digestive, mus- and stress-inoculation therapy (SIT) [26]. Eye move-
culoskeletal, nervous system and respiratory disorders ment desensitization retraining (EMDR) has also
[8–10]. Personality disorders such as borderline and anti- been found efficacious for PTSD [27]. PE, which was
social personality disorder are more common among developed by the second author, has been examined
individuals with PTSD compared with those without in the largest number of empirical studies in indepen-
PTSD [11,12]. dent research centers. It is for this reason that we focus
The high level of psychiatric and medical comorbid- our review on PE, while acknowledging that there are
ity among individuals with PTSD presents a significant several other psychotherapies that have demonstrated
challenge to arrive at an accurate diagnosis. There are efficacy treating PTSD.
many PTSD symptoms that overlap with those of fre-
quently co-occurring disorders. For example, dimin- Description of PE therapy for PTSD
ished interest in activities may be present in both PTSD PE is a manualized exposure therapy program that
and MDD. Similarly, irritability is common to PTSD involves three main components:
and GAD. Difficulty sleeping and concentration prob- • In vivo exposure to trauma reminders, typically
lems are symptoms of PTSD, MDD and GAD. Panic completed as between-session assignments;
attacks are characteristic of panic disorder but may
also be present in individuals with PTSD. This high • Imaginal exposure to the memory of the traumatic
degree of symptom overlap between PTSD and comor- event, completed during and between sessions;
bid conditions is especially problematic because PTSD • Processing of imaginal exposure.
has a heterogeneous presentation with many different
232 Clin. Pract. (2014) 11(2) future science group
The use of prolonged exposure therapy to help patients with PTSD Review
There are two additional minor components: Evidence supporting the use of PE
• Psychoeducation about the nature of trauma and Numerous randomized trials indicate that PE is
trauma reactions; effective in reducing PTSD symptoms [28]. Exposure
therapy has been found effective for both acute and
• Training in slow diaphragmic breathing. chronic PTSD [26,29], and studies show that gains
made during treatment are maintained at follow-ups
PE typically consists of eight to 15 individual 90-min of 1–5 years [30,31]. PE has been associated with rapid
sessions delivered once or twice weekly. change and maintenance of large effect sizes over time
Therapy begins with the clinician providing a ratio- [32,33]. Exposure therapy was identified in the joint Vet-
nale for exposure therapy. The therapist explains that erans Affairs-Department of Defense Clinical Practice
PTSD symptoms are maintained by two factors: avoid- Guideline for PTSD [34] as “strongly recommended”
ance of thoughts and feelings related to the trauma for use with veterans with PTSD. A 2008 report issued
and avoidance of trauma reminders; and the presence by the Institute of Medicine (IOM) concluded that
of unhelpful, distorted beliefs such as “the world is exposure therapy was the sole treatment for PTSD with
extremely dangerous” and “I am extremely incompe- sufficient evidence for its efficacy. This conclusion is
tent”. PE alters these negative, distorted perceptions by consistent with practice guidelines from the American
providing opportunities for experiential learning (i.e., Psychiatric Association [35], the Departments of Veter-
exposure) that disconfirms them. In addition, during ans Affairs and Defense (2004) and the International
the first session, patients learn a diaphragmatic b reathing Society for Traumatic Stress [36].
technique that they can use to reduce daily stress. PE has been associated with significantly greater pre-
The second session involves a discussion of com- to post-treatment reduction in PTSD symptomatology
mon reactions to trauma, which provides patients when compared with waitlist [23,26,28,37–40], supportive
with a framework for understanding their symptoms. counseling [41,42], relaxation [33,43–44] and treatment as
Next, the clinician introduces in vivo exposure, which usual [45–48]. A meta-analysis found that PE was associ-
refers to confronting avoided places, people and objects ated with large effect sizes compared with control con-
that remind the patient of the trauma. The clinician ditions at post-treatment and at follow-up [49]. Other
and patient collaboratively construct a hierarchical meta-analyses that have examined the efficacy of expo-
list of safe or low-risk situations that the patient has sure therapy in general have shown that exposure ther-
been avoiding. In vivo exposure is conducted in a step- apy was more effective than waitlist control or support-
wise fashion, beginning with situations that provoke ive therapy [50], and that exposure therapy is associated
moderate anxiety, and gradually progressing to more with a lower dropout rate than pharmacotherapy [51].
challenging situations. Some meta-analyses have found that exposure therapy
In session 3, the clinician provides the rationale for is more effective than nontrauma-focused treatments
imaginal exposure, which is conducted from session 3 or waitlist/control at reducing PTSD symptoms, but
through to session 10. Imaginal exposure involves ask- have not found significant differences in outcomes
ing the patient to confront the memory of his or her among specific exposure therapies [52–54]. In sum, the
trauma by revisiting it in their imagination and recount- evidence in support of the efficacy of exposure therapy
ing it in detail aloud for approximately 30–45 min. Ima- in general, and PE specifically, is extensive.
ginal exposure is followed by 15–20 min of ‘processing’,
in which the clinician and patient discuss thoughts and Does PE work for comorbid populations?
feelings about the trauma and about themselves, with As noted, patients rarely present with PTSD in the
the aim of helping the patient to develop a more realis- absence of additional psychiatric and physical health
tic and helpful perspective on the event itself and their problems. More often, PTSD sufferers face addi-
behaviors and emotions during the event. Processing the tional comorbidities such as depression and substance
imaginal exposure allows patients to articulate and inte- use, and associated symptoms such as dissociation
grate new information and insights into their memory. and elevated anger. The most useful treatment for
Patients are instructed to listen to an audio recording of PTSD, therefore, is one that demonstrates efficacy
the imaginal exposure each day as homework. among PTSD sufferers with and without commonly
The remaining sessions follow a standard agenda that co-occurring disorders.
begins with homework review, followed by imaginal PE has been found effective in reducing PTSD
exposure and processing, and ending with the assign- symptoms among patients with comorbid depression.
ment of homework exposure exercises for the coming In a study examining the impact of depression on the
week. The final session involves reviewing progress, efficacy of PE, comorbid depression was found to be
discussing lessons learned, and relapse prevention. unrelated to decrease in PTSD symptoms [55,56]. Those
future science group www.futuremedicine.com 233
Review McLean & Foa
with current major depression, past major depression SIT or their combination, and found that women with
and no history of major depression all benefitted equally BPD symptoms benefited as much from treatment as
from PE. Interestingly, patients with higher depression those without these symptoms [64]. Indeed, patients
in baseline who received either CPT or PE showed with BPD symptoms evidenced significant improve-
greater improvement in PTSD symptoms from pre- to ment on PTSD symptoms, PTSD diagnostic status,
post-treatment than those with lower d epression [57]. depression, anxiety and social functioning.
Importantly, PE has not only been found effective Similar results were found in a study that examined
among those with PTSD and comorbid depression, but women with comorbid BPD and PTSD with recent
it has also been found to significantly reduce depressive and/or imminent serious intentional self-injury [69] who
symptoms in a number of studies [26,38,43,58]. Thus, the received PE concurrently with dialectical behavior ther-
presence of comorbid depression is not a contraindica- apy (DBT). The results showed that DBT PE resulted
tion to PE treatment. However, in cases where major in significant reductions in PTSD, and at post-treat-
depression is the primary disorder, or when patients are ment a majority of patients no longer met criteria for
at a high risk for suicide, therapists must first provide PTSD. Importantly, DBT PE did not exacerbate PTSD
crisis management and containment. or BPD symptoms, including self-injurious behavior.
Many treatment studies for PTSD have excluded The finding that dissociative symptoms did not
patients with comorbid substance dependence dis- interfere with PE contradicts the previously held con-
orders [23,24] due to concern that substance use will cern that dissociation would reduce the efficacy of
interfere with patients’ ability to benefit from PTSD PTSD treatment by limiting emotional engagement
treatment and/or for fear that PTSD treatment will [70,71]. In contrast to Harned et al.’s hypothesis, pre-
exacerbate substance use. However, studies examin- treatment levels of trait dissociation, depersonalization,
ing the efficacy of PE with this population have found numbing and depressive symptoms were not related to
positive results. PE was shown to be effective in reduc- improvement or dropout [69]. Patients with high lev-
ing PTSD symptoms among patients with PTSD and els of dissociative symptoms showed a similar reduc-
comorbid alcohol dependence [59], and among those tion of PTSD as patients with low levels of dissociative
with comorbid cocaine dependence [60]. PE was not phenomena. In sum, there is no evidence to date that
associated with increased substance use in either of the dissociative phenomena predict treatment outcome.
aforementioned studies. Interestingly, Foa et al. found PE has also been shown to significantly reduce symp-
that patients who received PE were also less likely to toms that are commonly associated with PTSD. As
increase their drinking 6 months after treatment ter- noted above, these include depressive symptoms [26,40]
mination [59]. Thus, PE not only reduces PTSD symp- and alcohol use [59]. In addition, PE has been shown to
toms in this population, but can also help maintain significantly reduce general anxiety [23], trauma-related
reductions in drinking behavior. guilt [40], state-anger [72], and improves social adjust-
Traumatic brain injury (TBI) is frequently comor- ment and functioning [23]. PE, with or without the addi-
bid among PTSD patients, especially active military tion of cognitive restructuring, has also been shown to
personnel and veterans, because brain injuries are often significantly decrease reported physical health difficul-
sustained in traumatic experiences. A recent study of ties compared with waitlist, and these improvements
veterans with PTSD found that PE was equally effec- persisted at 12 months post-treatment [73]. In sum, PE
tive in individuals with and without a history of TBI can have a broad impact on the lives of PTSD suffer-
[61]. Regardless of TBI status, veterans with PTSD ers by reducing both PTSD severity and a ssociated
showed a significant reduction in PTSD severity post- symptoms, and improving overall f unctioning.
treatment. Although there is little research on this issue
at present, the results of this study provide promising Challenges to implementing PE
evidence that PE can be helpful for individuals with Although PE and several other evidence-based treat-
PTSD and a history of mild TBI. ments have been found effective in significantly reduc-
Patients with PTSD and borderline personality ing symptoms of PTSD and associated problems, it is
disorder (BPD) have also been excluded from some important to note that some patients drop out of treat-
treatment studies, especially when they report recent ment or do not achieve a good response. A drop-out
intentional self-injury [62–67]. Personality disorders, par- rate of approximately 20–30% has been found for both
ticularly BPD, have been thought to impede the effects exposure and nonexposure treatments [74], and up to
of treatment of PTSD [68]. However, research suggests 40–50% of patients do not achieve a good response [75],
that individuals with PTSD and comorbid BPD can defined as >70% reduction in symptoms. Research on
also benefit from PTSD treatment. Feeny, Zoellner predictors of dropout and response is currently lacking.
and Foa re-analyzed data of patients who received PE, One exception is a study that examined assault-related
234 Clin. Pract. (2014) 11(2) future science group
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