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Prolonged Exposure Treatment for PTSD

Post traumatic stress disorder (PTSD) is a chronic, often debilitating mental health disorder that may develop after a traumatic life event; such as military combat, natural disaster, sexual assault, or unexpected loss of a loved one. Most of the U.S. population is exposed to a traumatic event during their lifetime, and shortly after that exposure, many people experience some symptoms of PTSD. Although among most individuals these symptoms resolve within several weeks, approximately 10%–20% of individuals exposed to trauma experience PTSD symptoms that persist and are associated with impairment.

A number of psychological treatments for PTSD exist, including trauma-focused interventions and non-trauma-focused interventions. Trauma-focused treatments directly address memories of the traumatic event or thoughts and feelings related to the traumatic event. For example, both Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are trauma-focused treatments. Non-trauma-focused treatments aim to reduce PTSD symptoms, but not by directly targeting thoughts, memories and feelings related to the traumatic event. Examples of non-trauma-focused treatments include relaxation, stress inoculation training (SIT) and interpersonal therapy.

Prolonged Exposure is based on emotional processing theory, which suggests that traumatic events are not processed emotionally at the time of the event. Emotional processing theory suggests that fear is represented in memory as a cognitive structure that includes representations of the feared stimuli, the fear responses, and the meaning associated with the stimuli and responses to the stimuli. Fear structures can represent realistic threats, which is normal. However, fear structures can become dysfunctional. They may become problematic when the association between stimulus elements does not accurately reflect the real world. PE focuses on altering fear structures so that they are no longer easily triggered. Two conditions are necessary for fear structures to be altered and for exposure to work. First, the fear structure must be activated and second, new information that is incompatible with the incorrect information in the fear structure must be incorporated into the structure.

PE includes psycho-education about PTSD and common reactions to trauma, breathing retraining, and two types of exposure: in vivo exposure and imaginal exposure. During psycho-education, patients learn about PTSD, common reactions to trauma and exposure. Breathing retraining is a skill taught to assist patients in stressful situations but not to be used during exposure. The two main components of treatment are in vivo exposure and imaginal exposure. In vivo exposure assists patients in approaching situations, places and people they have been avoiding because of a fear response due to the traumatic event repeatedly until distress decreases. Imaginal exposure consists of patients approaching memories, thoughts and emotions surrounding the traumatic event they have been avoiding. Patients recount the narrative of the traumatic event in the present tense repeatedly and tape record this recounting to practice imaginal exposure for homework. The patient and therapist then process emotional content that emerged during the imaginal exposure. Through these two types of exposures, patients activate their fear structure and incorporate new information. PE has been shown to be helpful across survivors, in different cultures and countries, regardless of the length of time since traumatization or the number of previous traumatic events.

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