PE for PTSD: Mechanisms and Cornerstones

Barbara-Rothbaum

Associate Vice-Chair of Clinical Research, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
Director, Emory Healthcare Veterans Program
Director, Emory Trauma and Anxiety Recovery Program
Paul A. Janssen Chair in Neuropsychopharmacology

Key Points

  1. Prolonged exposure therapy for PTSD operates on addressing avoidance and promoting emotional processing by confronting trauma memories and safe reminders.
  2. The therapy involves changing the fear structure in the patient’s memory, with a focus on changing the narrative around feared stimuli, responses, and their meanings.
  3. Imaginal and in vivo exposures are crucial techniques in PE, leading to a decrease in distress and the reframing of traumatic events, thus aiding in the recovery process.
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Prolonged exposure (PE) therapy effectively addresses post-traumatic stress disorder (PTSD) by targeting two main aspects: avoidance and promoting emotional processing. This approach involves two types of exposure:

  1. Imaginal exposure: The patient confronts the trauma memory mentally.
  2. In vivo exposure: The patient confronts safe reminders of the trauma in real-life scenarios.

Theoretical Framework

The theoretical basis of PTSD in PE therapy is understood as a ‘fear structure’ within the patient’s memory, which acts as a programmed response for escaping perceived danger. This structure encompasses:

  • Feared stimuli: Examples include a tall bald man or being alone in a house at night.
  • Fear responses: Such as freezing, screaming, heart pounding, or crying.
  • Meaning of stimuli and responses: Typically, these are associated with a sense of imminent danger.

Process of Exposure and Correction

Through repeated and prolonged exposure to trauma reminders, both in thought (imaginal exposure) and in real life (in vivo exposure), patients experience a decrease in distress. This process involves two critical learnings:

  1. Distress decreases even while confronting the fear-inducing situation or memory.
  2. The anticipated negative outcome (the subject of the fear) does not occur.

This method aims to ‘rewrite’ the fear structure with corrective information based on these experiences.

Techniques in Imaginal Exposure

During imaginal exposure, the therapist assists the patient in repeatedly confronting the trauma memory, leading to a natural reduction in distress. The process involves:

  • Recounting the memory: Understanding what happened and the patient’s actions or inactions.
  • Therapeutic inquiry: The therapist asks specific questions to elucidate the patient’s changing perceptions and memories across sessions.

Addressing Self-Blame and Context

A key part of therapy is addressing the context of the traumatic event. For instance, actions deemed necessary in a war zone might be judged harshly in civilian life. Patients often realize, through repeated exposure, that their actions were appropriate given the context, helping them to reframe their self-perception and reduce self-blame.

Reframing Trauma Narratives

Patients often hold onto narratives that exacerbate their PTSD, such as feeling personally responsible for negative outcomes in uncontrollable situations. Through detailed discussions and revisiting of the traumatic event, patients can develop a more realistic understanding of the event, often leading to a significant shift in their perspective.

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PE for PTSD: Mechanisms and Cornerstones