The Veterans Health Administration is always looking for ways to improve psycho-therapy treatment of post-traumatic stress disorder. Two leading methods are known as cognitive processing and prolonged exposure. VA’s top expert on the problem recently co-authored the report on an extensive study that compared the two therapies. Joining the Federal Drive with Tom Temin with more is that expert. She’s the executive director of VA’s National Center for PTSD, Dr. Paula Schnurr.
Tom Temin: Dr. Schnurr, good to have you on.
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Paula Schnurr: Good morning.
Tom Temin: Well, first of all, tell us the context here. Where does the PTSD office that you head live within VA? And how does it interconnect with the other health care delivering mechanisms?
Paula Schnurr: The National Center for PTSD is a multi-site consortium that does research and education and consultation on PTSD. We’re part of VA’s Office of Mental Health and Suicide Prevention in the Veterans Health Administration. And we’re a virtual organization and so we’re at multiple sites across the country.
Tom Temin: All right, and with respect to PTSD, tell us what these two major psychotherapeutic types of treatments are in the first place.
Paula Schnurr: So if I could also begin this by saying PTSD is a treatable disorder. And so the context for this study is that we have a range of effective treatments. Prolonged exposure, known as PE, cognitive processing therapy, known as CPT, are among the most widely studied and most effective. VA began implementing a national training program in these treatments back in 2006, to enhance veterans’ access. And so we require that veterans at all VA medical centers have access to these treatments. So the context is these treatments are effective, VA was using them. But there had only been one head to head comparison. It was done a long time ago, and it was done in female civilians.
Tom Temin: All right, so you looked at it for a wider population and for its more general efficacy of these two types of treatments?
Paula Schnurr: Yes. And we did it in veterans who have been engaged in other research on these treatments, but not in the head to head.
Tom Temin: Got it. And just briefly describe how they work, the two different treatments.
Paula Schnurr: So they’re both known as trauma focused treatments, and trauma focus treatments help a person get through PTSD and related symptoms by helping them change their thoughts and feelings about a traumatic experience. Usually people have feelings such as fear and anger, sadness, guilt, they have thoughts that the world is dangerous or that they’re incompetent because they allowed something so bad to happen to them. And both of the treatments are trying to change these thoughts and feelings but in different ways. Prolonged exposure uses the technique of repeatedly telling one story in vivid detail until the feelings decrease. If you do something repeatedly, you can decrease negative feelings associated with a traumatic experience. Cognitive processing therapy instead focuses on the thoughts that go along with the traumatic experience. And so for homework, for example, in cognitive processing, you might do some worksheets to help you examine, say the pros and cons of believing the world is a dangerous place. In prolonged exposure, you might listen to a tape of yourself narrating the experience or go someplace out in the world that reminds you of the experience.
Tom Temin: It sounds like maybe these things should be done simultaneously though?
Paula Schnurr: Sometimes they are actually, and in truth, in both therapies, we’re working on thoughts and feelings. But in the cognitive processing therapy, the thoughts are the target and prolonged exposure, the feelings are the target. But in essence, because thoughts and feelings influence one another, we are working on both of them in both therapies.
Tom Temin: We were speaking with Dr. Paula Schnurr. She is executive director of VAs National Center for PTSD. And what did the study tell you?
Paula Schnurr: The study told us that both treatments are effective, which we had seen from other studies going in that prolonged exposure was a bit more effective, but not to a great degree. So it was a statistical difference, but it wasn’t a meaningful difference. And so what this tells us, our interpretation of the findings, is that providers can use these with high confidence about their effectiveness for veterans, and veterans can engage in either treatment, knowing that these treatments have been shown to be comparable.
Tom Temin: Well, if a veteran presents her or himself to a psychotherapist, and that person believes they have PTSD, does the therapist flip a coin? Or is there some indicator we know of that this treatment would be better for this individual that treatment for that individual?
Paula Schnurr: Well, that’s a great question, because that’s actually a question that we are going to be answering with this study. What works best for which kinds of patients. I imagine many of your listeners have heard about precision medicine. Usually it’s related to cancer treatment. But it’s also a very relevant question for mental health disorders. And I hope that within the coming year, we’ll be able to report on whether certain types of people may benefit more from one treatment or the other. But right now, what happens when people go to therapy will vary, but usually there’s some discussion of the pros and cons of different treatments, and what would be involved in doing one treatment versus the other. Formally, this process is known as shared decision making. And we recommend it in our paper, because it’s so important to help anyone with PTSD learn about their PTSD and the treatment options available to them.
Tom Temin: In this is there any substantive difference between veterans who might be suffering from PTSD as a result of a wartime situation, versus the general population that has a thousand causes that can result in PTSD?
Paula Schnurr: Well, veterans live in the civilian world before and after the military. So what’s unique is that many veterans have deployed to a war zone, and they have combat exposure, which is really quite rare for most people other than civilians who have been in conflict zones. But there’s much more similarity between veterans and non-veterans, then there are pronounced differences. And in fact, in our study, all veterans had military-related PTSD. But some of them chose to focus on civilian traumatic experiences that they had before or after the military, because those were the most troubling experiences for them.
Tom Temin: Yes, you answered my question. But someone could be a veteran having had battle experience. But then 10 years later, they could be in a terrible car crash or something. And so does PTSD sort of compound over time? Or can you get over one and then get it again?
Paula Schnurr: The answer to both questions is yes. Things can get worse over time. And the more traumatic experiences that you have, we’ve heard that, that which does not kill you shall make you stronger, but it’s not always true. And sometimes if you’ve had a traumatic experience, whether or not you’ve gotten PTSD, whether or not you’ve gotten over it, having a new traumatic experience can make things worse, and increase the likelihood of developing symptoms, or worsening symptoms that someone already has.
Tom Temin: And have you treated people for PTSD? I know you’re in the research end of things now. But what are some of the improvements that you’ve been able to see yourself?
Paula Schnurr: So I am not a clinician, and so I have not treated people with PTSD. But I’ve been in the field since the mid 1980s. I started doing PTSD research shortly after the diagnosis was formalized. And the biggest change that I’ve seen in the almost 40 years of research that I’ve done is that we now know PTSD is a treatable disorder. And as I said, we have effective treatments for PTSD. And back in the 80s, we didn’t have anywhere near the knowledge about PTSD and how to treat it. So I always try to say that what’s really changed besides broader awareness about what PTSD is, and that happens to both veterans and non-veterans, is that we now have psychotherapies and medications that we can use to treat it.
Tom Temin: Yes, that was another side question. Sometimes medication and psychotherapy work in tandem also, don’t they?
Paula Schnurr: They do and they’re often used in tandem. Right now, the best psychotherapies work better than the best medications for PTSD. But there’s an active amount of research going on to identify better medications for PTSD.
Tom Temin: And I’ll bet it gets complicated if there is PTSD in the presence of traumatic brain injury, two separate situations, but sometimes they occur simultaneously, also.
Paula Schnurr: They do. In fact, the kind of event that could cause a traumatic brain injury could also lead to PTSD. The good news is that at least for mild to moderate traumatic brain injury, those individuals seem as responsive to PTSD treatment if they have PTSD, compared with people who have not had a traumatic brain injury. So theoretically, it could complicate the picture, but it seems to really have an effect more so if an individual has severe consequences of the brain injury.
Tom Temin: And finally, what are some of the metrics for being cured of PTSD? Since you can’t quantify it in the way you can say, a bullet wound or a cut?
Paula Schnurr: Well, in all mental disorders, we use a combination of interviews and questionnaires to assess a person’s status and their improvement. There’s great interest in what we call biomarkers and having biological indicators, but we’re very far from being able to assess PTSD or improvement in PTSD. So the gold standard is a clinician interview using structured standardized questions, and that’s what we use in this study. But questionnaires are also widely used and can be very helpful as well.
Tom Temin: And so the person conducting that questionnaire would not have been the same person that conducted the psychotherapy leading to the cure?
Paula Schnurr: That’s correct. The best practice at least would be to have a person who’s independent and unaware of the kind of treatment or whether somebody’s had treatment in order to give the most objective assessment of the PTSD symptoms.
Tom Temin: Fascinating stuff. Dr. Paula Schnurr is executive director of VA’s National Center for PTSD. Thanks so much for joining me.
Paula Schnurr: Thank you for having me.
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