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This page contains information and summaries of published research that are intended for people with professional training in mental health.  We urge caution since it may be difficult to know how to interpret the information without advanced training in psychology or psychiatry.

We recommend that readers interested in information intended for the general public check other areas of this web site (such as Info for Adults or Info for Children).  They contain similar information, but in a more readable form.  Also, elsewhere we have provided links to other websites that we feel may be helpful.

CONSIDERATIONS AND CONTRAINDICTIONS FOR PROLONGED EXPOSURE FOR POSTTRAUMATIC STRESS DISORDER

Considerations in making decisions about initiating treatment:

·         PTSD has a better prognosis if clinical intervention is implemented as early as possible following a trauma.  It is generally believed that chronic PTSD becomes more difficult to treat as time passes, intrusive symptoms become less prominent, and avoidant symptoms increase (Foa et al., 2000).

o        However, note that PTSD is not the usual outcome after a person has been exposed to a traumatic event.  Some traumatic events such as sexual assault, MVAs, or exposure to combat are more likely to result in PTSD than others.

·         While Prolonged Exposure is a treatment that is associated with some degree of stress, research on this concern has found that only a minority of clients report temporary symptom exacerbations that subside before the end of treatment.

o        10.5% reported a temporary increase in PTSD symptoms, 21.1% reported increases in anxiety, and 9.2% an increase in depression at the start of the exposure portion of treatment

o        These temporary exacerbations did not result in an increased dropout rate and did not have a negative impact on treatment outcome (Foa et al. 2002)

Factors that may predict less positive response to treatment (van Minnen & Hagenaars, 2002; van Minnen et al, 2002; Taylor et al, 2001).:

·         More severe pretreatment numbing

·         In auto accident survivors, greater anger about their car crash

·         Lower levels of global functioning

·         Greater pain severity and interference

·         Use of antidepressant or anxiolytic medication is associated with poorer outcome.

·         Alcohol use and benzodiazepine use are also associated with higher drop out rates

·         Very high anxiety at the beginning of exposure (although not “general” anxiety)

Factors that may predict more positive response to treatment (van Minnen & Hagenaars, 2002; van Minnen et al, 2002; Taylor et al, 2001).:

Factors that have been found to be unrelated to response or outcome (van Minnen & Hagenaars, 2002; van Minnen et al, 2002; Taylor et al, 2001).:

·         Possible Contraindications for Prolonged Exposure: The following issues are common indications that PE for PTSD may not be an appropriate treatment for a particular client, or that progress in amelioration of another concern is necessary before PE for PTSD can begin (Foa & Rothbaum, 1998)

o        “It seems that patients with pervasive dysfunction and/or high comorbidity are especially resistant to first-line therapy.  These patients may be especially good candidates for programs that include multiple treatment modalities such as meditation, psychotherapy, family therapy, and rehabilitation therapy.” (Foa et al., 2000)

o        although disputed by recent research, findings to date suggest that intense anger interferes with modification of traumatic memory by preventing habituation  (Foa & Rothbaum, 1998).  Realistic guilt about committing a bad act (e.g., harming someone, etc.) may significantly reduce the chance of a positive outcome in therapy.

§         Guilt, shame, and anger may indicate that modification of PE to address cognitive restructuring, or using other treatments with empirical support like SIT or CPT, may be appropriate.  These approaches may vary in that:

·         In addition to cognitive restructuring, modifications may include: additional relaxation skills, practice with guided self-dialogue, role playing, and modeling behaviors.

·         Practice of these skills may first focus on their application in non-trauma evoking situations, and then gradual generalization to trauma related situations. 

·         “Inpatient treatment should be considered when the individual is in imminent danger of harming self or others, has destabilized or relapsed significantly in the ability to function, is in the throes of major psychosocial stressors, or is in need of specialized observation/evaluation in a secure environment.” (Foa et al., 2000).

o        Significant risk of suicide or violence

o        Psychotic symptoms

o        Psychological symptoms of significant severity that prevent the client from functioning or actively participating in treatment

·         Other potential contraindications:

o        Active substance dependence or abuse

o        Significant dissociative symptoms

o        Neuropsychological deficits

o        Mental retardation

o        Cardiovascular disease

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The information posted on this site reflects our understanding of peer-reviewed research and generally accepted principles in psychology.  It is not intended to be used for self-treatment or as a substitute for individualized assessment and treatment by a licensed professional, and should not be construed as professional advice.

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