Treatment of PTSD in Older Adults: Do Cognitive-Behavioral Interventions Remain Viable?ā˜†,ā˜†ā˜†

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Abstract

The literature examining trauma among older adults is growing, but little is known about the efficacy of empirically supported interventions for PTSD within this population. Clinical writing on this topic often implies that cognitive-behavioral treatments may be ineffective or inappropriate for older adults with PTSD given physical and/or cognitive vulnerabilities. Review of the limited research in this area, however, provides little support for the claim that cognitive-behavioral interventions are ineffective in treating PTSD among the elderly. In an effort to explicate specific issues related to treatment process and outcome among older survivors of trauma, a case series is presented outlining the treatment of three older adults within the context of a structured, cognitive-behavioral group intervention. Observations from this case series suggest that cognitive-behavioral interventions continue to be useful in treating PTSD with this population. Specific treatment issues unique to older adults are explored and recommendations for future research are discussed.

Section snippets

PTSD in the General Population and in Older Adults

PTSD is conceptualized as an anxiety disorder developing in response to traumatic events involving actual or threatened death, serious injury, and/or threat to one's physical integrity (American Psychiatric Association, 2000). Symptoms include reexperiencing the event (e.g., intrusive thoughts, dreams, and/or flashbacks), avoidance of thoughts and/or situations associated with the trauma, numbing of emotional responsiveness (e.g., detachment, flattened or absent affect), and heightened arousal

Treatment of PTSD: Controversy in Older Adults

Despite the chronicity associated with PTSD, several therapeutic approaches are supported in the literature. Currently, cognitive-behavioral therapies (CBT) have received the most empirical scrutiny and are considered the preferred treatment for PTSD (American Psychiatric Association, 2004, Keane et al., 2006). Principal components of these treatments typically include exposure and cognitive therapies. Exposure therapy for PTSD involves evoking distressing memories of the trauma via controlled

Case Example of Group CBT With Older Adults

To illustrate therapeutic process of CBT in older adults, we present data collected within the context of a cognitive-behavioral group intervention targeting motor-vehicle accident (MVA) related PTSD (Beck and Coffey, 2005, Beck et al., 2009). Specifically, we provide a series of case studies taken from a treatment group containing a subset of three older gentlemen. A number of points should be emphasized in outlining these vignettes.

Although the present data were not collected as part of a

Description of Treatment

Beck et al., 2009, Beck and Coffey, 2005) group CBT (GCBT) is based on Blanchard and Hickling's (1997) individual treatment program for MVA-related PTSD. GCBT consists of 14 weekly sessions each lasting 2 hours. Homework exercises serve a central role throughout treatment and focus primarily on exposure and cognitive techniques. The initial session is used for introductions, to provide guidelines for group therapy (e.g., confidentiality), and to review the rationale for treatment. Didactic

Matthew

Matthew was 72-year-old Caucasian male residing with his wife of 43 years. Matthew was retired but held a seasonal position at a local country club. A veteran of the Vietnam War, he reported witnessing a number of combat-related traumas but denied any ongoing distress as a result of these experiences. Matthew had been diagnosed with and successfully treated for colon cancer 2 years earlier. He reported no ongoing physical complications or medication use associated with this diagnosis.

Matthew's

Assessment

Diagnoses of PTSD and comorbid disorders were established via clinical interview conducted during the initial assessment (pretreatment) and 1 month following the completion of the program (posttreatment). PTSD diagnoses were established using the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990). CAPS items also were summed to provide a continuous index of PTSD severity (CAPS severity; scores ranging from 0 to 136). Interviews were conducted by advanced graduate students supervised

Outcome: Pre- and Posttreatment Assessment

PTSD diagnoses, CAPS total, IES-R, and BDI-II scores at pre- and posttreatment are presented in Table 1. Means and standard deviations from the Beck et al. (2009) trial are provided as a reference for the current case series. Interview and self-report data reveal some variability among the three men. Consistent with diagnostic interviews, Matthew evidenced the lowest scores on all three measures at pretreatment. Although his IES-R and BDI-II scores were comparable to those observed in the Beck

Outcome: Trajectory Across Therapy

Pre- and post-treatment data suggest an overall positive response to GCBT. Scores collected throughout the course of treatment provide a detailed picture of how these changes occurred. Consistent with low levels of initial symptomology, Matthew's IES-R and BDI-II data indicate a fairly flat treatment response (see Figures 1a and 1b). Matthew was perhaps the most verbally engaged of the three older adults in this group and was generally compliant with homework assignments. Because his symptoms

Impact of Advanced Age on Outcome and Process

A number of important points should be noted given the criticisms of cognitive-behavioral interventions with older trauma survivors. In-group discussion and review of weekly homework indicated no greater difficulty with exposure or cognitive-based interventions than members in the larger Beck et al. (2009) clinical trial. All three men participated in weekly, between-session exposure exercises with no evidence of physical complications. These results are consistent with previous case studies

Future Directions

Because the literature concerning PTSD in the elderly remains in its early stages, continued research on any number of topics is welcome. A number of specific areas seem particularly relevant given the present review. The association of advanced age with lower rates of PTSD and greater posttrauma functioning appears to be relatively robust across studies and trauma samples (e.g., Acierno et al., 2006, Frueh et al., 2007). Notwithstanding potential method effects, what factors account for this

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    ā˜†

    This research was supported in part by grants from the National Institute of Mental Health awarded to J. Gayle Beck (MH64777) and Joshua D. Clapp (F31 MH083385).

    ā˜†ā˜†

    The authors would like to thank Sarah A. Palyo, Ph.D. for her role as co-therapist for the current treatment group.

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