Prolonged Exposure Therapy for Older Veterans With Posttraumatic Stress Disorder: A Pilot Study

doi:10.1097/JGP.0b013e3182435ee9

The American Journal of Geriatric Psychiatry

Volume 20, Issue 3, March 2012, Pages 276-280

https://doi.org/10.1097/JGP.0b013e3182435ee9 Get rights and content

Objectives

The purpose of this pilot study was to assess the feasibility and preliminary efficacy of prolonged exposure psychotherapy in older Veterans with posttraumatic stress disorder (PTSD). Exposure therapy has broad empirical support for PTSD, but it has not been studied systematically in older adults, partly due to published concerns that older adults would not tolerate the treatment.

Methods

The trial followed a prospective pre-post design of 11 men recruited from a Veterans Affairs (VA) PTSD Clinical Team program. After baseline assessment, eight participants completed prolonged exposure therapy. Results were compared with a nonrandomized treatment-as-usual comparison group. The traumatic events identified by the Veterans in our samples had occurred, on average, 40 years prior to their study participation.

Results

Results revealed that conducting 6 weeks of exposure therapy with older Veterans with PTSD was feasible and efficacious, with evidence of some superiority to treatment-as-usual therapy.

Conclusions

As hypothesized, Veterans showed a significant decrease in symptoms of PTSD (clinician-rated and self-reported) following exposure therapy.

Section snippets

Participants

All participants sought care from the PTSD Clinical Team at the VA San Diego Healthcare System. Study inclusion criteria included 1) PTSD due to a military event; 2) age 55 years or older; and 3) no change in type or dosage of psychotropic medications in the past 2 months. Exclusion criteria were 1) lifetime history of psychosis or manic episode; 2) alcohol or other substance dependence in past 6 months; and 3) alternate psychotherapy for PTSD concurrent with the study.

Clinician-Administered PTSD Scale⁷

The

RESULTS

Twenty-three subjects were referred to the study. Of the 12 Veterans who were referred but not enrolled, 3 did not complete the screening process and 9 were not eligible, mostly because they did not meet full PTSD criteria. Among the 11 Veterans enrolled, 3 dropped out before completing treatment (1 moved out of state, 1 had scheduling conflicts, and 1 was diagnosed with cancer and chose not to continue) and did not return for posttreatment assessment. This dropout rate (27%) is similar to that

DISCUSSION

This study suggests the feasibility of recruitment, assessment, and exposure-based treatment of older Veterans with PTSD from distant military-related events. The traumatic events identified by the Veterans in our samples had occurred, on average, four decades prior to the study. Despite the chronic nature of the PTSD, Veterans who completed 6 weeks of PE showed a significant reduction in clinician-rated and self-reported PTSD symptoms. Using the interpretation of CAPS scores suggested by

References (19)

MB Powers et al.
A meta-analytic review of prolonged exposure for posttraumatic stress disorder
Clin Psychol Rev
(2010)
SR Thorp et al.
Meta-analysis comparing different behavioral treatments for late-life anxiety
Am J Geriatr Psychiatry
(2009)
Bottche M, Kuwert P, Knaevelsrud C: Posttraumatic stress disorder in older adults: an overview of characteristics and...
LA King et al.
Assessing late-onset stress symptomatology among aging male combat veterans
Aging Ment Health
(2007)
SA Rauch et al.
Prolonged exposure for PTSD in a Veterans Health Administration PTSD clinic
J Trauma Stress
(2009)
PP Schnurr et al.
Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial
JAMA
(2007)
SR Thorp et al.
Prolonged exposure therapy for older combat veterans in the VA Healthcare System
DD Blake et al.
The development of a Clinician-Administered PTSD Scale
J Trauma Stress
(1995)
JE Hovens et al.
The assessment of posttraumatic stress disorder: with the Clinician Administered PTSD Scale: Dutch results
J Clin Psychol
(1994)

There are more references available in the full text version of this article.

Cited by (58)

Prolonged Exposure Therapy With an Older Adult: An Extended Case Example
2022, Cognitive and Behavioral Practice
Prolonged exposure therapy (PE) has gained strong empirical support for posttraumatic stress disorder (PTSD) in the general population. However, some authors have suggested that exposure therapies may be less effective for the treatment of PTSD in older adults. There is a paucity of empirical treatment studies for older adults with PTSD. The extant studies are briefly reviewed. There are indications that exposure therapies can be feasible, safe, and efficacious for older adults. However, the degree and maintenance of gains may be reduced in older adults relative to younger adults. A case example is presented to provide a detailed illustration of PE conducted with an older adult. The treatment is presented in five phases, including standard treatment components and suggested modifications for older adults. The modifications include careful use of terminology, slowing down the presentation of some information, involvement of family members, and utilizing technology to minimize the negative effects of physical impairments and stigma.
Cognitive treatment of post-traumatic stress disorder in the elderly. A longitudinal study
2021, Encephale
Citation Excerpt :
In the cases studied, PTSD symptoms were qualitatively and quantitatively reduced during treatment. Indeed, a recent literature review indicates that treatment of PTSD in the elderly, based on exposure techniques, provides at least significant systematic improvements in trauma symptoms [36], while a pilot study conducted on 11 war veterans showed that six sessions of trauma exposure improved short-term symptomatology [32]. However, the data are still scarce and no longer-term scientific research seems to have validated the initial results from these case studies [37].
This article aims to verify whether a cognitive treatment of post-traumatic stress disorder (PTSD) by cognitive behavioural therapy (CBT) adapted to elderly subjects can lead to long-term improvement in symptomatology and quality of life.
We present a longitudinal study of 32 subjects over the age of 65 years, with no cognitive impairment or mild impairment, residing in two nursing homes. We compare a target group (n = 16) with PTSD treated with 20 CBT sessions and a control group (n = 16) with PTSD without symptom treatment. The two groups are compared in four stages: (T1) before treatment of the target group's PTSD, (T2) after treatment of PTSD, (T3) after six months of follow-up and (T4) after 18 months of follow-up. The absence of cognitive impairment is verified with the MMSE. The evolution of PTSD is monitored with the CAPS. The evolution of the quality of life of the subjects in the target group is verified with the ADRQL.
If both groups show elevated PTSD symptoms at the beginning of the study (T1), the signs of PTSD disappear for the target group at the end of treatment (T2) at the same time as quality of life improves (scores more than doubled). These improvements continue for more than 18 months (T4). Conversely, the control group retains high PTSD symptoms, without significant decrease over time.
The treatment of PTSD by cognitive-behavioural therapy adapted to elderly people without cognitive impairment, or with mild cognitive or memory disorders, allows for a lasting disappearance of symptoms and an improvement in quality of life.
Depuis quelques années, l’étude des traumatismes psychiques chez les personnes âgées devient un terrain de recherche incontournable en raison du vieillissement de la population. Cependant, encore peu de preuves existent quant à l’opportunité des traitements psychologiques du trouble de stress post traumatique (TSPT) au sein de cette population, comparativement aux populations plus jeunes. Les quelques études de cas sur le sujet indiquent que les interventions de type cognitives et comportementales peuvent être efficientes, mais les auteurs divergent sur la question de leur efficacité prolongée en raison des troubles cognitifs, médicaux et sensoriels des sujets âgés. Cet article cherche à vérifier si un traitement cognitif du TSPT par thérapie cognitive et comportementale (TCC) adaptée aux sujets âgés peut permettre une amélioration à long terme de la symptomatologie et de la qualité de vie.
Nous présentons une étude longitudinale menée auprès de 32 personnes âgées de plus de 65 ans (sujets âgés de 72 à 89 ans ; m = 81,32), sans trouble cognitif ou avec des troubles légers, résidant dans deux maisons de retraite. Notre échantillon de population est composé de deux groupes : (1) un groupe cible (n = 16) présentant un TSPT et pris en charge par 20 séances de TCC suivant un guide écrit, et (2) un groupe contrôle (n = 16) présentant un TSPT sans traitement des symptômes par refus de toute prise en charge psychologique motivé par les participants. Les patients ne sont inclus dans l’étude qu’après avoir pu exprimer un consentement éclairé et avoir accepté, avec accord du médecin traitant, de ne pas modifier leur traitement psychiatrique pendant la durée de l’étude. Les deux groupes sont comparés lors de quatre temps : (T1) avant le traitement du TSPT du groupe cible, (T2) après le traitement du TSPT, (T3) après six mois de suivi et (T4) après 18 mois de suivi. Pour les patients du groupe contrôle, tous ont donné leur consentement pour continuer à participer aux ateliers psychologiques et cognitifs de l’établissement et bénéficier d’entretiens hebdomadaires avec le psychologue. L’absence de trouble cognitif est vérifiée avec le MMSE. En accord avec le niveau d’éducation, sont retenues les personnes présentant un score minimum supérieur à 23 sur 30 (26–30 indiquant une absence de pathologie et un score supérieur à 23 ou 25 selon le niveau d’éducation signifiant une atteinte cognitive légère). L’évolution du TSPT est suivie avec la CAPS en suivant la règle que plus le score obtenu est élevé, plus la sévérité et la fréquence des symptômes est importante. L’évolution des cinq domaines essentiels de la qualité de vie des sujets du groupe cible est vérifiée avec l’ADRQL en suivant la règle que plus le score obtenu est élevé, meilleure est la qualité de vie.
Les données recueillies indiquent que les deux groupes sont homogènes et présentent des symptômes de TSPT élevés en début d’étude (T1) avec un score global moyen (CAPS) de 76,11 pour le groupe cible et de 76,13 pour le groupe contrôle (valeur de p > 0,01). En fin de traitement (T2), les signes du TSPT disparaissent pour le groupe cible (passent en dessous du seuil de détection du TSPT pour les symptômes de reviviscence, d’évitement et d’hyper-éveil). Le score moyen global (CAPS) passe de 76,11 à 8,19 pour le groupe cible (valeur de p < 0,01) alors qu’il se maintient à 76,62 pour le groupe contrôle. En même temps, la qualité de vie s’améliore pour le groupe cible (scores plus que doublés pour chacun des cinq domaines de la qualité de vie) avec un score global moyen (ADRQL) passant de 179,66 en T1 à 440,27 en T2 (valeur de p < 0,01). Ces améliorations se prolongent sur plus de 18 mois (T4) avec des scores restant identiques à ceux enregistrés en fin de traitement. À l’inverse, le groupe contrôle conserve des symptômes élevés de TSPT, sans diminution significative de la symptomatologie au cours du temps. Les comparaisons statistiques entre les deux échantillons de population réalisées avec le T-test indiquent que les différences observées sont significatives (valeur de p < 0,01 lors des comparaisons intergroupes à T2, T3 et T4).
Le traitement du TSPT par une thérapie cognitive et comportementale adaptée aux personnes âgées sans trouble cognitif, ou avec des troubles cognitivo-mnésiques légers, permet une disparition durable des symptômes ainsi qu’une amélioration de la qualité de vie. Si nos données doivent encore être complétées, nos résultats indiquent qu’il n’y aurait pas de risque à utiliser des thérapies cognitives chez le sujet âgé pour traiter sur le long terme les traumatismes psychiques.
Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis
2019, Journal of Anxiety Disorders
Citation Excerpt :
Participants with exposure to terror-related trauma were assigned to the mixed trauma category because this was the only study that included terror-related trauma. Studies by Rauch et al. (2009) and Thorp et al. (2012) also reported combat, assault, and mixed trauma type categories. However, only the combat trauma participants were included for these two studies because of small sample size (n < 3) in the other trauma categories (see Fig. 3).
There is conflicting evidence as to whether military populations (i.e., veteran and active-duty military service members) demonstrate a poorer response to psychotherapy for posttraumatic stress disorder (PTSD) compared to civilians. Existing research may be complicated by the fact that treatment outcomes differences could be due to the type of trauma exposure (e.g., combat) or population differences (e.g., military culture). This meta-analysis evaluated PTSD treatment outcomes as a function of trauma type (combat v. assault v. mixed) and population (military v. civilian). Unlike previous meta-analyses, we focused exclusively on manualized, first-line psychotherapies for PTSD as defined by expert treatment guidelines. Treatment outcomes were large across trauma types and population; yet differences were observed between trauma and population subgroups. Military populations demonstrated poorer treatment outcomes compared to civilians. The combat and assault trauma subgroups had worse treatment outcomes compared to the mixed trauma subgroup, but differences were not observed between assault and combat subgroups. Higher attrition rates predicted poorer treatment outcomes, but did not vary between military populations and civilians. Overall, manualized, first-line psychotherapies for PTSD should continue to be used for civilians and military populations with various trauma types. However, greater emphasis should be placed on enhancing PTSD psychotherapies for military populations and on treatment retention across populations based on findings from this meta-analysis.
A randomized controlled trial of prolonged exposure therapy versus relaxation training for older veterans with military-related PTSD
2019, Journal of Anxiety Disorders
Although prolonged exposure (PE) has strong support for treating posttraumatic stress disorder (PTSD), there is little research on PE for older adults. Likewise, Relaxation Training (RT) has shown some benefit for PTSD, but has not been adequately tested in this population.
This study represents the first randomized controlled trial of two active psychotherapies for PTSD among older adults. Male combat veterans (N = 87; mean age = 65 years) were randomly assigned to 12 sessions of PE (n = 41) or RT (n = 46). Clinician-administered and self-report assessments were conducted at pre-treatment, post-treatment, and six-month follow-up; self-reported symptoms were also measured at each treatment session.
Multi-level modeling indicated that Clinician-Administered PTSD Scale scores significantly decreased from pre-treatment to follow-up, but the time by treatment condition interaction was not significant. Pre- to post-treatment change was large in PE and moderate in RT, but many gains were lost at follow-up. For self-reported PTSD symptoms, a significant time by treatment condition interaction emerged, suggesting that participants who received PE had both greater decreases in symptoms and a greater rebound in self-reported PTSD symptoms than those who received RT. Unlike PTSD symptoms, depression symptoms neither changed nor were moderated by treatment condition from pre-treatment to follow-up. For self-reported PTSD and depression symptoms assessed at each session, time significantly predicted symptom reductions across psychotherapy sessions.
PE and RT are well-tolerated, feasible, and effective for older adults, though treatment gains were not maintained at follow-up.
clinicaltrials.gov Identifier: NCT00539279.
Post-traumatic stress disorder secondary to Alzheimer's disease: Emergence of an underlying pathology in the oldest old
2017, Annales Medico-Psychologiques
Le grand âge donne lieu à des tableaux sémiologiques complexes, où se mêlent des pathologies variées, dont l’expression est liée à influence de l’histoire de vie. Les interrelations entre pathologies psychiatriques et neuro-dégénératives sont de ce fait particulièrement mal connues. Il est pourtant possible de préciser les relations entre état de stress post-traumatique et maladie d’Alzheimer, à travers la caractérisation des symptômes psychiatriques et cognitifs, ainsi que de l’autobiographie du patient. Cette approche est illustrée par le cas d’un homme, ancien combattant de 93 ans. Le recueil de l’histoire de vie, dont les attitudes liées au partage des informations sur les événements traumatogènes, ainsi que des caractéristiques psychopathologiques concernant les deux pathologies selon une perspective vie entière a permis de montrer qu’après plusieurs dizaines d’années d’adaptation aux souvenirs traumatiques, la perte d’autonomie cognitive était associée à l’émergence d’un état de stress post-traumatique retardé.
Old age leads to complex semiologies, mixing several diseases, whose expression is linked to the influence of life history. Accordingly, even if neurodegenerative diseases today constitute one of the main diseases affecting aging people, the interrelations between neurodegenerative and psychiatric disorders are particularly poorly understood. Two assumptions coexist about the interrelation between post-traumatic stress disorders and dementias. According to the first one, post-traumatic stress disorders contribute or worsen neurodegenerative disorders. The second one supposes that dementias lead to late-onset post-traumatic stress disorders. In the absence of regular life-long health follow-up, the entanglement of both symptomatologies in the oldest age people makes impossible to valid one or the other or both. It is however possible to clinically precise the relations between post-traumatic stress disorder and Alzheimer's disease through the characterization of cognitive and psychiatric symptoms, and also through the collection of patient's autobiography. This approach is illustrated by the case of a 93-year-old veteran, living in a nursing retirement home. His neurodegenerative disorder had altered his memory and his executive abilities. His discourse was coherent, with temporal distortions and intrusions of real recent events. He presented all diagnostic criteria for post-traumatic stress disorder, with numerous repetitions of intrusive memories of war events in which he was powerless, amnesia for some elements of the trauma, and major efforts to avoid thinking about wartime. Yet, he had demonstrated a willingness to share his memories with his family as soon as he returned from war. The collection of life story, including information sharing behaviors about the traumatogenic events, and psychopathology characteristics of both pathologies in a life-course perspective showed that the Alzheimer's disease revealed a post-traumatic stress disorder. After several decades of adaptation to traumatic memories, cognitive autonomy loss was associated with the emergence of late-onset post-traumatic stress disorder.
Efficacy and Feasibility of a Therapist-Guided Internet-Based Intervention for Older Persons with Childhood Traumatization: A Randomized Controlled Trial
2017, American Journal of Geriatric Psychiatry
Citation Excerpt :
Research with other samples of German World War II survivors also indicates low levels of depressive and anxiety symptoms,35,36 which might point to a specificity of the subgroup. Therefore, no comorbidity with typical trauma-related mental symptoms could be identified that is contrary to the literature.2,12 Integrative TT was associated with a significant increase in quality of life and self-efficacy from pre- to post-treatment with moderate within-effect sizes.
Although cognitive-behavioral treatment approaches for post-traumatic stress disorder (PTSD) exist, only a small proportion of older adults seeks psychological treatment. Alternative treatment approaches are thus needed to fill the gap between provision and use of psychological interventions. This study aimed to investigate the efficacy and feasibility of an Internet-based, therapist-guided cognitive-behavioral therapy (Internet-based CBT) for older individuals with PTSD symptoms.
Patients with clinically meaningful (i.e., subsyndromal or greater) PTSD symptoms were randomly assigned to a 6-week treatment group of therapist-guided Internet-based CBT (N = 47; treatment group) or a wait-list group (N = 47; WL). The treatment group was assessed pre- and post-treatment as well as at 3-, 6- and 12-month follow-ups.
Linear mixed-effects analyses showed a significant interaction between group (treatment versus WL) and time (pre versus post) for PTSD symptoms with a moderate between-group effect size in favor of the treatment group (d = 0.42). Effects in the treatment group were maintained up to the 12-month follow-up. Findings indicate a significant interaction (group × time) for quality of life (d = 0.39) and self-efficacy (d = 0.38). With regard to the feasibility, attrition rate was very low in both groups (treatment group: 12.8%, WL: 6.4%) and working alliance was very high.
Results suggest that therapist-guided Internet-based CBT is associated with a substantial reduction in PTSD symptoms, and increase in resource-related variables in older adults with (subsyndromal) PTSD. This Internet-based intervention may offer a promising option in a stepped-care approach for older trauma-affected persons who may otherwise not pursue mental health treatment.

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Dr. Thorp was awarded seed funding for this project from the Advanced Center for Innovation in Services and Interventions Research (PI: DVJ). Dr. Thorp's work is currently supported by a Career Development Award from the VA.

There are no disclosures to report.

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Brief ReportProlonged Exposure Therapy for Older Veterans With Posttraumatic Stress Disorder: A Pilot Study

Objectives

Methods

Results

Conclusions

Section snippets

Participants

Clinician-Administered PTSD Scale7

RESULTS

DISCUSSION

Clin Psychol Rev

Am J Geriatr Psychiatry

Assessing late-onset stress symptomatology among aging male combat veterans

Aging Ment Health

Prolonged exposure for PTSD in a Veterans Health Administration PTSD clinic

J Trauma Stress

Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial

JAMA

Prolonged exposure therapy for older combat veterans in the VA Healthcare System

The development of a Clinician-Administered PTSD Scale

J Trauma Stress

The assessment of posttraumatic stress disorder: with the Clinician Administered PTSD Scale: Dutch results

J Clin Psychol

Brief Report
Prolonged Exposure Therapy for Older Veterans With Posttraumatic Stress Disorder: A Pilot Study

Clinician-Administered PTSD Scale⁷