Managing Comorbidities in PE Therapy for PTSD

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.

Highlights

  • Comorbidity is the rule rather than the exception with PTSD.
  • Treating PTSD is the best way to help with other problems. Maintain the focus on PTSD.
  • If a crisis arises without imminent risk, adhering to the treatment plan is the best way to address the crisis.

 

Transcript

Video 7: How to Manage Comorbidities.
Maintaining the Focus of Treatment on PTSD During Chaos and Crises.

Comorbidity of other psychiatric disorders with chronic PTSD is common. Depression, dysthymia, other anxiety disorders, alcohol and substance abuse and dependence are examples of common comorbid disorders. In addition, patients with chronic PTSD often face multiple life stressors leading to chaotic lifestyles. Therefore, crises during treatment are quite usual—especially if early or multiple traumatic experiences have interfered with the development of healthy coping skills.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Poorly modulated affect, self-destructive impulse control problems—for example, alcohol binges or risky behaviors—numerous conflicts with family members or others, and severe depression with suicidal ideation are not uncommon in those with chronic PTSD. These problems require attention, but can potentially disrupt the focus of treatment of PTSD.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

If careful pre-treatment assessment has determined that chronic PTSD is among the patient’s primary problems, our approach is to maintain the focus on PTSD with periodic reassessment of other problem areas as needed.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

If the patient’s mood or behaviors cause imminent concern about his personal safety or the safety of others, the need to attend to this prominent risk may require postponing PE.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

However, if crises arise without imminent risk, explain to the patient that adhering to the treatment plan and thereby decreasing PTSD symptoms and associated problems is the best way to address the crisis. This is because many crises are directly or indirectly associated with the PTSD symptoms. In maintaining this focus, you must clearly express support for the patient’s desire to recover from PTSD. Communicate a strong belief that the patient wants to get better. Applaud every step in the direction of healthy coping and adherence to the treatment program.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

If appropriate, you may label and externalize crises as related to the PTSD and predict that these situations will improve as the patient’s skills improve and PTSD symptoms decline.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

The aim is to provide emotional support throughout the crises and, at the same time, keep PTSD as the major focus of treatment. It’s a powerful learning moment for the patient to feel in crisis yet maintain the agenda in the session and see that he accomplished something by staying the course. As we discussed in previous videos, we recommend that if it’s not an imminent crisis that requires attention, find a way to keep PE as the focus of your treatment and stick to the agenda for that session.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

You can tell the patient that it’s important what they’re going through and will discuss it, but let’s stick to the agenda first and discuss it at the end of the session if there’s time. Typically, the patient feels better at the end of the session about what they were worried about.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Reducing PTSD depression or related symptoms as well as increasing the patient’s sense of confidence and self-efficacy will facilitate his ability to cope better with crises in the future as well as to prevent them.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.

Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Key points from this video: Comorbidity is the rule rather than the exception with PTSD. Treating PTSD is the best way to help with other problems. Maintain the focus on PTSD. Teach them you can be anxious and do it anyway. Depression, dysthymia, other anxiety disorders, and alcohol and substance abuse and dependence are examples of comorbid disorders with PTSD. If a crisis arises without imminent risk, explain to the patient that adhering to the treatment plan and thereby decreasing PTSD symptoms and associated problems is the best way to address the crisis.

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