Treatment of a police officer with PTSD using prolonged exposure

BEHAV1ORTHERAPY30, 527--538, 1999

Treatment of a Police Officer With PTSD Using Prolonged Exposure DAVID E TOLIN EDNA B. FOA

University of Pennsylvania Exposure therapy has been demonstrated to be an effective treatment for posttraumatic stress disorder (PTSD) in combat veterans, rape victims, accident survivors, and other traumatized populations. However, little is known about the efficacy of exposure therapy for emergency services personnel diagnosed with PTSD. The present singlesubject report describes the successful implementation of this therapy with a police ofricer diagnosed with chronic PTSD following a work-related incident. Using a timeseries design, we found that symptom relief was clearly associated with the onset of exposure therapy, and persisted after termination of this therapy through a 6-month follow-up period. Hypothesized mechanisms for the efficacy of exposure therapy are discussed, as are future studies for the treatment of PTSD in emergency workers. Recently, several researchers have called attention to the prevalence o f t r a u m a - r e l a t e d p s y c h i a t r i c disturbance, particularly P T S D , a m o n g e m e r g e n c y service workers. M c F a r l a n e (1986) s u r v e y e d volunteer firefighters w h o had b e e n involved in a serious brush fire and f o u n d that 4 months after the fire, 32% w e r e identified as p r o b a b l e psychiatric cases using cutoff scores on the 12-item G e n e r a l Health Q u e s t i o n n a i r e ( G H Q ; G o l d b e r g , 1972), a m e a s u r e o f general p s y c h i a t r i c distress. T w e n t y - n i n e months after the fire, 21% o f the firefighters still r e p o r t e d intrusive i m a g e r y o f the fire that interfered with normal functioning. U s i n g d i a g n o s t i c interviews, M c F a r l a n e and P a p a y (1992) f o u n d a 12.5% prevalence rate o f P T S D a m o n g the firefighters. B r y a n t and H a r v e y (1995) r e p o r t e d that 37% o f a s a m p l e o f volunteer firefighters r e p o r t e d posttraumatic stress s y m p t o m s , and 24% r e p o r t e d s y m p t o m s that were attributed specifically to w o r k - r e l a t e d traumas. P o l i c e officers, like firefighters, are e x p o s e d to a high frequency o f potenThe authors thank Dr. Jonathan Abramowitz for his comments during the preparation of this manuscript, and Dr. Richard Cohen for his assistance with in vivo exposure and for conducting supplementary diagnostic interviews. Address correspondence to David Tolin, Ph.D., Center for Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, 3535 Market St., 6th Floor, Philadelphia, PA 19104. 527 005-7894/99105274)53851.00/0 Copyright1999by Associationfor Advancementof BehaviorTherapy All rightsfor reproductionin any formreserved.

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tially traumatic events during the course of duty (Violanti, 1996) and therefore may be at increased risk of developing PTSD. Gersons (1989) found that among police officers involved in shootings, 46% met diagnostic criteria for PTSD and another 46% reported subclinical but significant posttraumatic stress symptoms. Conversely, Alexander & Wells (1991) found a low prevalence of psychiatric morbidity following traumatic experience among police officers. Although this inconsistency may be due to the different nature of the traumas and the measurements used in the two studies, clinical observations strongly suggest that at least some emergency service workers do develop PTSD following work-related traumatic incidents. Compared to PTSD in combat veterans (Horowitz, 1976; Kardiner, 1941; Keane, Zimering, & Caddell, 1985; Kulka et al., 1988) and female survivors of rape and sexual assault (Burgess & Holmstrom, 1974; Kilpatrick, Saunders, Veronen, Best, & Von, 1987; Rothbanm, Foa, Riggs, Murdock, & Walsh, 1992), PTSD in emergency service workers is less well understood. Some theorists have posited that police officers with PTSD are likely to view themselves as weak, damaged, or incompetent; to be hyperalert and view the world as excessively dangerous; and to feel excessive guilt and shame about their performance during the traumatic event (e.g., Mann & Neece, 1990). Clinical observation suggests a high premorbid frequency of impulsive or sensationseeking behaviors among police officers, which can become exaggerated following a traumatic event. As Mann and Neece point out, these behaviors may increase the already high risk of harm that is inherent in the line of duty. In addition to its symptom profile, PTSD among emergency service workers is also unique due to the nature of the traumatic event. Repeated exposure to life-threatening and frightening events is part of the emergency service worker's job, and they are therefore likely to encounter traumatic stressors during the course of duty. When emotional reactions to stressors are poorly managed, the stressors may produce a cumulative detrimental effect on psychological well-being (Reiser & Geiger, 1984). The number of stressful experiences predicts PTSD symptoms related to a traumatic event (Moran & Britton, 1994). Second, unlike most other populations, emergency service workers with PTSD usually are traumatized during the course of duty. Thus, reminders of traumatic events are available at a high frequency throughout the work day, and can be difficult to avoid. Repeated exposure to trauma reminders may result in habituation and decreased symptoms for some; however, for others it may result in more drastic forms of avoidance (e.g., resignation). The person's interruption of work and subsequent removal from institutional and social support networks has been associated with further increases in PTSD symptomatology (Bryant & Harvey, 1995). The past 2 decades have witnessed vast improvements in PTSD treatments. Some of the most efficacious interventions incorporate some form of exposure to aversive trauma cues. Exposure therapy for PTSD involves imaginal exposure, such as, deliberately recounting the trauma, and/or in vivo exposure, such as, exposing the patient to stimuli that remind him or her of the

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trauma and have been subsequently avoided (Foa & Rothbaum, 1998). Exposure therapy has been shown to be effective for PTSD following combat (Fairbank & Keane, 1982; Keane, Fairbank, Caddell, & Zimering, 1989; Keane & Kaloupek, 1982), sexual and nonsexual assault (Foa, Rothbaum, Riggs, & Murdock, 1991; Foa et al., in press), and motor vehicle accidents (McCaffrey & Fairbank, 1985). To date, no controlled study has examined the efficacy of exposure therapy with emergency service personnel with PTSD. In an uncontrolled case series with minimal assessment, Richards and Rose (1991) successfully employed a combination of imaginal and in vivo exposure to reduce PTSD symptoms in two police officers who suffered work-related traumas. These results are encouraging, but the lack of a controlled design limits the conclusions that can be drawn from the report. This paper describes the use of exposure therapy with a police officer with work-related chronic PTSD, using a time-series design (Barlow, Hayes, & Nelson, 1984; Cook & Campbell, 1979). The use of time-series methods, such as repeated measurement and no-treatment phases, can help to rule out the role of certain nonspecific effects, such as the passage of time and repeated assessment.

Method Client

Mr. R. is a 38-year-old male Caucasian police officer. He was referred to our clinic by his general practitioner, who had prescribed .025 mg alprazolam HS. Mr. R. stated that he believed he had become dependent on the alprazolam. He had also been treated unsuccessfully with fluoxetine and setraline for approximately 6 months, and had discontinued their use in the week prior to seeking treatment here. Mr. R. denied any history of major medical or psychiatric problems prior to the traumatic event, and never sought mental health treatment. He had been a good student in school, attended 2 years of college, served in the military, and became a decorated police sergeant. He described himself as a leader on the police force. Mr. R. described several traumatic experiences related to his work as a police officer, including witnessing a plane crash, finding dead and decomposing bodies, witnessing the death of a colleague from heart attack, witnessing a fatal motor vehicle accident in which a friend died, and being assaulted on duty. Mr. R. reported that the most significant traumatic incident occurred approximately 6 months prior to his presenting at our clinic. During the course of duty, Mr. R. was involved in a high-speed car chase. The car he was chasing collided with another, seriously injuring a civilian adult and infant. Mr. R. described looking into the victims' car and seeing both victims trapped in the car and covered in blood. He reported that after the collision a riot broke out and people threw objects at him. Mr. R. was unable to escape the scene. He stated that after this event he suffered a "nervous breakdown," experienced chronic depression and severe panic attacks upon exposure to

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reminders of the trauma, and began abusing alcohol (by the time of intake, he had decreased his alcohol intake to one beer per week). When he presented for treatment, he was on an indefinite disability leave from the police force due to his psychiatric symptoms, and it was unclear whether he would be able to return to work. He was socially isolated, and rarely left his home. Moreover, he had separated from his wife who left 6 weeks prior to his entering treatment. A pre-treatment semistructured interview indicated that Mr. R. suffered from chronic PTSD (DSM-F¢, American Psychiatric Association, 1994) as a result of the traumatic events described above. His specific symptoms included intrusive thoughts, nightmares, and flashbacks about the motor vehicle accident and the sight of the civilian victims, severe anxiety around trauma-related stimuli, such as urban areas, crowds, elevators, the sight of police officers, and his own police uniform and awards. He tried, albeit unsuccessfully, to avoid thinking about the trauma and confronting trauma reminders. As a result, he had very little social contact or recreational activities. He also complained of sleep problems, exaggerated startle, and hypervigilance. In addition to PTSD, Mr. R. met diagnostic criteria for major depressive disorder (single episode) and alcohol abuse in remission. Selfreport measures indicated that Mr. R. was severely depressed and highly anxious (see Table 1). In addition, he endorsed questionnaire items indicating that he viewed himself as incompetent and damaged, and the world as dangerous and unpredictable, and that he blamed himself excessively for the traumatic event.

Measures PTSD Symptom Scale-Self Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993). The PSS-SR consists of 17 items that correspond to DSMIII-R symptoms of PTSD. Each item is rated from 0 (no symptoms) to 3 (severe TABLE 1 PSYCHOPATHOLOGYMEASURESAT PRE-, POST TREATMENT, AND 6-MONTH FOLLOw-UP Measure PSS-SR Intrusion Avoidance Arousal PTCI Negative thoughts about self Negative thoughts about world Self-blame

Pretreatment 14 18 15 5.24 6.14 5.20

Posttreatment

Follow-Up

1 2 2

2 5 3

1.43 2.14 1.00

1.48 1.57 1.00

BDI

29

2

9

BAI

35

5

5

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symptoms). The PSS-SR shows good internal consistency and is sensitive to treatment effects. Post-Traumatic Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, in press). The PTCI is a 36-item self-report measure of cognitive distortions specific to PTSD. It measures cognitive factors that have been highlighted in qualitative case reports of police officers with PTSD (e.g., Mann & Neece, 1990) and appears to be more specific to PTSD than are other measures of trauma-related cognitions. The PTCI has good internal consistency and excellent discrimination of trauma survivors with and without PTSD. The PTCI consists of three subscales: negative cognitions about self, negative cognitions about the world, and self-blame. Scale scores range from a low of 1 to a high of 7. Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbangh, 1961). The BDI is a 21-item self-report measure of depression that has high reliability and validity. The BDI is routinely used in studies of depression, and has been used with several anxiety disorders, including PTSD. Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988). The BAI is a 21-item self-report inventory for measuring the severity of anxiety. The BAI has good reliability and validity, and has been used in a large number of studies across diagnostic boundaries. PTSD Symptom Scale-Interview Version (PSS-I; Foa et al., 1993). The PSS-I is a semistructured interview designed to assess current symptoms of PTSD as defined by DSM-IV criteria. The PSS-I shows adequate reliability and validity (Foa et al.), and compares favorably to other structured interviews for PTSD (Foa & Tolin, 1998). The PSS-I was used to confirm the diagnosis of PTSD at pretreatment, posttreatment, and follow-up. Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1995). The SCID is a structured interview measuring DSM-IV disorders. The mood, anxiety, and psychosis modules of the SCID were used to assess comorbid psychopathology.

Procedure Assessment. Evaluations were conducted before and after treatment, and at 3 months posttreatment. Each evaluation included a diagnostic interview, including the PSS-I and selected modules from the SCID to assess PTSD diagnosis and severity and comorbid psychopathology, and PSS, PTCI, BDI, and BAI. In addition, Mr. R. completed the PSS-SR prior to each session, and the BDI every 2 weeks. Design. An intensive time-series design (Barlow et al., 1984) was used. Treatment consisted of a three-session measurement-only period to measure severity and stability of symptoms, followed by a five-session treatment phase, and a second three-session measurement-only phase to assess the stability of therapeutic change. Mr. R. completed self-report inventories of symptom severity at each assessment point. More comprehensive assessments were administered at pretreatment, immediately following treatment, and 6 months posttreatment.

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Treatment sessions. The initial measurement-only phase (three sessions over 3 weeks) consisted of gathering information about Mr. R.'s symptoms and general functioning. During this phase educational information about trauma and PTSD was provided, the rationale for exposure therapy was presented, and a hierarchy of trauma-related situations that the patient avoided was constructed. This hierarchy included a list of situations that were avoided but were realistically safe. These situations were, in increasing order of fear: looking at his police awards, watching police-related television shows, wearing his police uniform, entering crowded or confined areas, visiting the site of the collision, and riding in a police vehicle. However, Mr. R. was instructed not to approach these situations during this initial phase, and he reported that he did not do so until instructed in the treatment phase. The treatment phase was based on Foa and Rothbaum's (1998) protocol for rape-related PTSD and consisted of five weekly, 90-minute exposure sessions conducted by the first author. Imaginal exposure was conducted within the session, and in vivo exposure was assigned as homework. For imaginal exposure, Mr. R. recounted the details of his traumatic experiences for 60 minutes per session. The first memory to be addressed in this fashion was the car chase that resulted in civilian injuries. We selected this memory because Mr. R. identified it as his most distressing memory. During the treatment session, Mr. R. was instructed to imagine the event as vividly as possible, "as if it were happening now", and to describe it aloud in the present tense. He was encouraged to include details about the event itself, and his thoughts, emotions, and physical sensations during the event. These details were included to facilitate activation of cognitive fear networks (Foa & Kozak, 1986). At times, the therapist prompted Mr. R. to include such details. Mr. R. was also asked to provide Subjective Units of Discomfort (SUD) ratings prior to beginning imaginal exposure, every 5 minutes during the exposure, and immediately following the exposure. The exposure was continued after 15 minutes or after Mr. R.'s SUD ratings had decreased by 50%, whichever came first. After the exposure, Mr. R. discussed his thoughts and emotions about the exercise with the therapist. This process was repeated for about 1 hour during which the memory was recounted approximately four times. The imaginal exposure sessions were recorded on audiotapes and Mr. R. was instructed to recall the memory daily, as homework, by listening to the tape and trying to imagine the event as vividly as possible. This memory was addressed using imaginal exposure for two treatment sessions, after which Mr. R.'s SUD ratings indicated that recalling the memory no longer caused him substantial distress. Mr. R. was then asked to identify the next most troubling memory. He selected a memory of chasing an armed suspect through a dangerous neighborhood. This memory was addressed in the same manner as above for 1 hour, until his SUD ratings indicated that he had habituated to the memory, at which time he was instructed to go home and listen to the audiotape of that day's exposure session. The next two treatment sessions were conducted in the same fashion, by asking Mr. R. to identify his most disturb-

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ing memory and then spending approximately 1 hour recounting the memory. For the last two exposure sessions he selected a memory of being assaulted by a suspect and a memory of recovering the body of a child who had been beaten to death. After exposure to these memories, Mr. R. was no longer able to identify any traumatic memories that were particularly distressing to him. The remaining 30 minutes of each session were spent planning in vivo exposure. Mr. R. was instructed to confront safe situations that he feared, beginning with those that evoked moderate levels of anxiety and progressing to increasingly more fearful situations. For example, in treatment session 1 he was instructed to take his police awards out of storage, hang them on the walls of his home, and sit in his living room looking at the awards. Mr. R. indicated that he had completed the assignment, and although he felt anxious at first, by the next day he no longer felt upset while looking at the awards. In session 2, he was encouraged to watch and videotape police-related television shows, such as "COPS" and to watch the most bothersome parts of the show, such as car chases, over and over. He was also instructed to wear his police uniform at home. In sessions 3 and 4, he was instructed to enter and remain in crowded or confined areas, such as shopping malls, restaurants, and elevators. During session 4, Mr. R. was accompanied by the therapist as he rode an elevator; he then rode elevators alone as homework every day for that week. Finally, in session 5, he was instructed to visit the location of the collision and to ride in a police vehicle. During his visit to the site of the collision, Mr. R. was accompanied by a psychologist in his home town. To facilitate in vivo exposure, Mr. R. was given a self-monitoring log and was asked to record each exposure session, including pre-exposure, peak, and post-exposure SUD ratings. He was instructed to remain in each exposure situation for 1 hour or until his peak SUD ratings decreased by at least 50%, whichever came first. At the beginning of each session, self-monitoring logs were reviewed by the therapist. Review of his self-monitoring logs indicated good compliance with the therapist's instructions. To help modulate his anxiety level, Mr. R. was instructed in progressive muscle relaxation (Bernstein & Borkovec, 1977) and controlled breathing (Clark, Salkovskis, & Chalkley, 1985), which he was instructed to practice daily but not to use during exposure. He was further instructed to discuss reducing his alprazolam with his prescribing physician. He reported that he did so, and by session 3, he reported that he had discontinued use of alprazolam. Treatment was followed by a second measurement-only phase (three sessions over 6 weeks) during which treatment was discontinued and Mr. R.'s symptoms were assessed. Mr. R. did not receive any imaginal exposure to traumatic memories in session, and he reported that he did not listen to the audiotapes. He was not instructed to continue to enter anxiety-eliciting situations or to practice relaxation during this phase; however, he was not prohibited from doing so. During the interviews in the second measurement-only phase, Mr. R. reported that he continued to use these techniques, although in a less structured manner and for briefer periods of time than in the treatment phase.

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Results Mr. R.'s progress at each session was assessed using the PSS-SR and the BDI, the results of which are shown in Figure 1. As shown in Figure 1, during the first measurement-only phase Mr. R. showed some initial decrease in PTSD symptomatology, followed by a return to his initial levels. PTSD and depression were both in the severe range throughout this phase, ranging from 37 to 47 for the PSS-SR and 29 to 36, for the BDI. During the exposure sessions, Mr. R. typically exhibited significant distress, often becoming tearful or agitated. SUD ratings typically peaked around 85 (0 to 100 scale) and decreased to around 20. As shown in Figure 1, Mr. R.'s PSS-SR and BDI scores decreased moderately at first, then sharply following the fourth session. This sharp decline coincided with his approaching the items at the top of his in vivo hierarchy (riding in elevators and police vehicles, visiting the location of the collision), as well as complete abstinence from alprazolam. By the fifth session, Mr. R. was no longer able to generate mental images that elicited SUD ratings greater than 25, nor could he identify any situations that would cause him significant distress. Because of Mr. R.'s marked improvement, it was decided to end the active phase of treatment at that time and begin the second measurement-only phase. During the second measurement-only phase, Mr. R.'s PTSD and depressive symptoms remained low, as can be seen in Table 1 and Figure 1. His alcohol consumption had not increased, and he remained abstinent from alprazolam throughout the posttreatment measurement-only phase with the exception of

Measurement Only

50 45 40 35

Prolonged

Measurement

Exposure

Only

L/

PSS-SR Total 1 BDt

l

30

8 25 20 15 10 5 0

I

I

I

I

I

I

I

I

I

.IL

1

2

3

4

5

6

7

8

9

10

Session

FIG. 1.

PSS-SR and BDI scores by session.

JL 11

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one dose taken as a sleep aid. By the end of this measurement-only phase, Mr. R. reported that he had returned to his job as a police officer. He stated that he felt some anxiety when he first returned to work, but that he was able to control this anxiety using controlled breathing. He further related that he was enjoying being back at work, and that he was functioning well on the job. Because he reported continuing to use relaxation exercises and to enter previously avoided situations, it cannot be determined with certainty whether the improvement would have lasted had he received exposure only. As shown in Table 1, Mr. R.'s PTSD severity remained low at posttreatment as shown by the PSS-SR. His negative thoughts about himself and the world, as well as his self-blame, had decreased from the PTSD range to the non-PTSD range on the PTCI (Foa et al., 1998). His anxiety and depression levels had decreased to within the normal range as shown on the BAI and BDI, respectively. A diagnostic interview indicated that he no longer met DSM-IV criteria for PTSD or major depressive disorder. For work-related purposes, Mr. R. also met with an independent psychiatric assessor who reached the same conclusion. His symptoms and diagnostic status remained essentially the same at 6-month follow-up.

Discussion This case illustrates the efficacy of exposure therapy for PTSD in police officers with work-related traumas. Thus, it appears that this population at high-risk for exposure to traumas may respond to treatment in much the same way as do combat veterans (Fairbank & Keane, 1982; Keane, 1989; Keane et al., 1989; Keane & Kaloupek, 1982), female rape victims (Foa et al., 1991), and motor vehicle accident victims (McCaffrey & Fairbank, 1985). The client responded to treatment fairly rapidly compared to clients from other populations; it remains to be seen whether rapid treatment response is characteristic of emergency service workers in general. It has been suggested (Foa & Rothbaum, 1998) that PTSD results from trauma-related memory networks containing erroneous associations and interpretations, leading the victim to view himself or herself as completely incompetent, and the world as completely dangerous. It was further suggested that exposure therapy subsequently alleviates symptoms in part by activating cognitive fear networks and providing new information that is incompatible with existing pathological elements (Foa & Kozak, 1986). Observation of the present case is consistent with this hypothesis. As shown on the PTCI, Mr. R., when first presenting for treatment, endorsed items indicating that he viewed himself as incompetent and damaged, and the world as unsafe. As predicted by the emotional processing theory, imaginal and in vivo exposure generated an anxiety reaction (as indicated by SUD peaks and clinical observation). Also, the exposure exercises showed Mr. R. that he was able to manage that distress and that nothing terrible happened when he confronted the feared situations. Consequently, his cognitions about himself and the world changed from pre-

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to posttreatment, becoming significantly more positive. His ideas of selfblame and guilt also diminished during exposure therapy, according to the PTCI. Guilt is commonly associated with PTSD (Kubany, 1994), and feelings of guilt and self-blame may be particularly pronounced among police officers involved in duty-related traumas (Mann & Neece, 1990). Pitman et al. (1991) identified guilt as a complicating factor in exposure therapy for PTSD, and suggested that strong feelings of guilt may require cognitive therapy or pharmacotherapy, or may contraindicate the use of exposure altogether. Though this may be true for many patients, Mr. R.'s feelings of guilt and self-blame were addressed effectively and efficiently using exposure. Thus, for at least some patients, exposure may be helpful in relieving excessive trauma-related guilt. Mr. R. also exhibited decreased depression during exposure therapy. It may be hypothesized that Mr. R.'s decrease in depression resulted from the cognitive changes measured by the PTCI, combined with the increased activity brought about by the in vivo exposure assignments. Though the precise cause of the decrease in depression is not clear, it is consistent with other reports (e.g., Foa et al., 1999; Nishith, Hearst, Diana, Mueser, & Foa, 1995) showing that prolonged exposure (PE) tends to decrease depression scores among PTSD patients. Thus, PE may be an effective intervention for comorbid depression in individuals with PTSD, and for many patients no additional intervention for depression may be needed. To our knowledge, this case is the most detailed demonstration of the cognitive behavioral treatment of PTSD in an emergency service worker, suggesting that this form of treatment holds promise for clinicians treating such personnel. However, the present report must be followed by studies using more controlled designs. Future studies should use group designs in which exposure therapy is compared to wait-list control or nondirective counseling, as has been done with other populations (Foa et al., 1991; Keane et at., 1989).

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