The Use of Prolonged Exposure Therapy Augmented With CBT to Treat Postpartum Trauma

Abstract

Approximately 1% to 2% of women suffer from posttraumatic stress disorder (PTSD) following childbirth, with obstetric emergencies being a key risk factor for birth-related PTSD. The current study augmented prolonged exposure (PE) with cognitive behavioral therapy (CBT) to treat symptoms of PTSD, anxiety, depression, panic disorder, and agoraphobia in a 28-year-old married Hispanic female following a life-threatening case of postpartum preeclampsia. To target distressing symptoms and reach treatment goals, the patient engaged in two preparatory sessions, 12 active PE sessions, and five supplementary CBT sessions. Posttreatment assessment indicated a significant reduction of anxiety and depressive symptoms. Panic attacks reduced in frequency and severity, and by the end of treatment, the patient no longer met criteria for PTSD, major depressive disorder (MDD), or agoraphobia. In the case of postpartum PTSD, CBT can augment PE treatment to reduce symptomatology.

Keywords

PTSD postpartum preeclampsia prolonged exposure medical PTSD

1 Theoretical and Research Basis for Treatment

Posttraumatic Stress Disorder (PTSD)

The lifetime prevalence of PTSD is between 6.8% and 8.7% in the U.S. adult population (Kessler et al., 2005). Key features of the disorder include intrusive thoughts or reexperiencing of the event; avoiding thoughts, feelings, people, or situations connected to the event; experiencing negative alterations in mood or cognitions; and increased arousal (i.e., difficulty concentrating, irritability, easily startled; American Psychiatric Association, 2013). PTSD is highly comorbid with other psychiatric disorders, including major depressive disorder (MDD) and various anxiety disorders, including panic disorder, social phobia, and generalized anxiety disorder (GAD; Bleich, Koslowsky, Dolev, & Lerer, 1997; Franklin & Zimmerman, 2001; Spinhoven, Penninx, van Hemert, de Rooij, & Elzinga, 2014). Rates of comorbidity range from 30% to 50% (Angelakis & Nixon, 2015), and comorbidity among MDD, PTSD, and other anxiety disorders is associated with greater symptom severity, worse functioning, and higher incidence of suicidality (Kaufman & Charney, 2000). Despite high prevalence rates of comorbidity and the risks associated with multiple diagnoses, clinical guidelines on how to effectively treat clients with a comorbid presentation do not exist.

Furthermore, approximately 1% to 2% of women suffer from PTSD following childbirth (Andersen, Melvaer, Videbech, Lamont, & Joergensen, 2012). A review of the literature suggests that prenatal factors including a history of depression, anxiety, trauma, or sexual abuse may make an individual vulnerable to postpartum PTSD. Infant complications, low support during labor and delivery, psychological difficulties during pregnancy (i.e., depression/anxiety), and obstetric emergencies are the main risk factors for birth-related PTSD (Andersen et al., 2012). Loss of control during labor is also related to the development of PTSD symptoms (Andersen et al., 2012). In a sample of 149 women whose pregnancies were complicated by postpartum preeclampsia, PTSD prevalence was about 9% at 6 weeks and 5% at 12 weeks post partum. The prevalence of symptom clusters was even higher; about one fifth (22%) of the sample experienced symptoms of intrusion, 9% experienced avoidance, and 29% experienced hyperarousal at 6 weeks post partum. Symptoms reduced by 12 weeks post partum to 12% experiencing intrusion, 8% avoidance, and 20% hyperarousal. Younger age, severity of preeclampsia, cesarean section, lower gestational age, lower birth weight, admission to the neonatal intensive care unit (NICU), and perinatal death were associated with PTSD diagnosis (Hoedjes et al., 2011). The most effective treatment of postpartum PTSD has not yet been established; however, cognitive behavioral therapy (CBT) appears to be considered a first line of treatment in the United Kingdom (Ayers, Joseph, McKenzie-McHarg, Slade, & Wijma, 2008).

Prolonged Exposure (PE) Therapy

One of the most common and effective ways to treat PTSD is through PE therapy (Cusack et al., 2016). PE includes in vivo (real life) exposure to trauma reminders, imaginal exposure to the memory of the traumatic event (client recounts the trauma in the present tense), psychoeducation about trauma and trauma reactions, and training in controlled breathing. In 8 to 15 90-min sessions, PE aims to reduce avoidance of thoughts and images related to the trauma as avoidance maintains PTSD by preventing emotional processing and integration of the memory. Second, PE aims to target and correct erroneous beliefs through experiential learning or exposure. PE is rooted in models of fear conditioning, extinction, and emotional processing theory as outlined below (Foa, 2011).

Behavioral models of PTSD underline the role of Pavlovian conditioning in fear acquisition. According to the Pavlovian model, associative learning underlies the development and treatment of excessive fear. In the case of PTSD, the traumatic event is considered an unconditioned stimulus (US), which has been associated with other nonthreatening conditioned stimuli (CS). This may include certain smells, sights, sounds, and/or people. When an association between a neutral stimulus and the traumatic event is formed in memory, later exposure to the neutral stimulus will activate the representation of the trauma. This triggers a fear response, including avoidance, reexperiencing, and physiological reactivity. Conversely, extinction learning occurs when a CS is repeatedly presented in the absence of the US. This results in a decrease in fear responding (Colwill & Rescorla, 1986; Rescorla & Wagner, 1972).

Thus, the mechanism behind exposure therapy in treating PTSD is linked to the process of extinction. In PE, treatment requires repeated confrontation of feared thoughts, images, objects, situations, and/or activities in a safe environment. In vivo and imaginal exposures are repeated in the absence of the negative outcome to reduce pathological fear and anxiety. Learning theories of fear acquisition also highlight cognitive processes, including controllability and predictability of the traumatic event, which play a role in reducing fearful responses in the presence of a neutral cue (Mineka & Zinbarg, 2006; Ohman & Mineka, 2001). Importantly, exposure is not a process of unlearning or forgetting feared associations, but rather it involves new inhibitory learning and the formation of new associations that disrupt the CS–US expectancy (Bouton, 1993, 2004). In this sense, the original fear memory competes with the new extinction memory to affect the behavioral response. Return of fear responses may occur in contexts where the corrected or updated memory is not activated to inhibit the original fear memory (Foa, 2011). However, relapse rates are low following exposure therapy for PTSD when exposures are conducted repeatedly, in multiple contexts (Schnurr et al., 2007).

Emotional processing theory is also implicated in PE. Emotional processing theory posits that to successfully reduce pathological fear, treatment must first activate the fear structure and then provide new information that is incompatible with the existing fear structure. This is based on the notion that fear is represented in memory as a cognitive structure that includes information about the feared stimuli and fear responses (Foa & Kozak, 1985, 1986). PE achieves both objectives outlined in emotional processing theory as in vivo and imaginal exposures activate the fear structure. Once activated in a safe environment, learning occurs that disconfirms the feared outcomes. Repeated confrontations of the feared stimuli (in vivo) and/or feared memory (imaginal) helps correct exaggerated probability estimates of harm, organize the trauma narrative in memory, and reevaluate trauma-related cognitions (Foa, 2011). In addition to achieving these goals, it is also expected that the fear structure will later be activated in response to actual threat, rather than in objectively safe environments. In contrast, avoidance prolongs symptoms of PTSD by activating the fear structure in objectively safe situations. In this way, avoidance of feared situations and avoidance of retelling the trauma impede opportunities to obtain corrective information that would disconfirm feared consequences.

Empirical research studies support the finding that PE is an appropriate and effective method to treat PTSD (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). Furthermore, for an individual with a comorbid presentation of PTSD and MDD, PE can also safely and effectively reduce symptoms of depression (van Minnen, Harned, Zoellner, & Mills, 2012).

CBT

CBT has been used to treat a wide range of psychiatric disorders. It focuses on solutions to current problems by encouraging clients to challenge distorted cognitions and alter destructive patterns of behavior. A key tenet of CBT is understanding the way in which thoughts, emotions, and behaviors influence and are influenced by one another. Some studies suggest that augmenting exposure therapy with other CBT procedures has little to no effect on symptoms of PTSD (Foa, Rothbaum, & Furr, 2003); however, no research studies to date have examined the effect of augmenting PE with CBT for residual symptoms of MDD and anxiety.

2 Case Introduction

Sofia (name changed to ensure confidentiality), is a self-referred 28-year-old married Hispanic female who presented for individual therapy with symptoms of depression, generalized anxiety, panic disorder, agoraphobia, and PTSD following a life-threatening post partum illness in 2015, two and a half years prior to intake. As a teenager, she experienced a hurricane disaster, sexual assault, emotional abuse from her mother, and witnessed physical abuse from her mother toward her older brother, all precipitating factors for her mental health problems. Sofia also endorsed a family history of bipolar disorder, alcohol use disorder, anxiety, depression, and suicidality.

3 Presenting Complaints

Sofia presented two and a half years after post partum preeclampsia, which she reported as being traumatic for her. Sofia reported significant, impairing anxiety, primarily regarding her 2-year-old son’s health and well-being, for more than 6 months and that her symptoms were exacerbated by a recent hurricane that occurred 2 months prior to intake. More specifically, she reported feeling jittery, nervous, restless, having difficulty concentrating, being irritable, and having difficulty falling and staying asleep. In the days leading up to the hurricane, she began experiencing frequent unpredictable panic attacks. Panic attacks were also triggered by passing a hospital, seeing a baby, or hearing about pregnancy, following her own life-threatening case of post partum preeclampsia two and half years prior to intake. Her symptoms of depression, anxiety, and PTSD were significantly interfering with her daily life, including social relationships and her ability to maintain a job. Due to fear of experiencing a panic attack outside of the home, Sofia also avoided crowded public places, including the grocery store, restaurants, and theaters. Sofia entered treatment in the hopes that by processing her trauma, she would be able to reduce her anxious thoughts and worries, lift her mood, and “stop living in fear all the time.”

4 History

Sofia reported that she had experienced feelings of depression and anxiety on and off ever since she was a child. Her mother was emotionally abusive to her and physically abusive toward her older brother. When Sofia was 5-years old, her mother physically harmed her older brother. As a child, Sofia’s brother attempted suicide. She did not remember details of the event but was later told about it by her older sister.

Sofia recalls enduring painful taunting from her mother. Her mother would mock and make fun of her, call her names, and berate her with insults. At age of 10 years, Sofia attempted suicide by consuming a bottle of her mother’s sleeping pills. Her mother found her and brought her to a hospital where Sofia had her stomach pumped. She was released shortly thereafter but was not provided with medication or psychotherapy.

At age of 14 years, Sofia confided to a school counselor that she was feeling depressed. She began taking Paxil, which she reported was helpful. Two years later, her mother abruptly stopped her medication, after stating that she did not believe that Sofia was really depressed. Around that time, when Sofia was 16 years, she was raped by her ex-boyfriend, whom she dated for about 4 months. Although the two had broken up, they still frequently spent time together. One day, after the two had broken up, she went over to his house, and he forced her to have sex with him. After this incident, she told one friend but did not report the rape to any adult or authority figure. She stopped speaking to her ex-boyfriend and started experiencing panic attacks shortly thereafter.

In the same year, she also experienced a hurricane. During the hurricane, her parents thought they might die, and the family’s home was severely damaged. After the hurricane, they had to live several weeks without water and electricity while waiting for a check to arrive, at which point they were able to move.

Several years later, when Sofia was in her early 20s, she decided to enter therapy with a licensed clinical social worker (LCSW). Her grandmother’s passing, frequent panic attacks, and nightmares regarding her past rape were all precipitating factors which led her to seek treatment with this LCSW. She reported some benefit after 12 months of treatment.

At age of 26 years, 2 months after her wedding in 2015, Sofia found out she was pregnant. She experienced several challenges during her pregnancy. At 6 weeks, she was told by a doctor that there were two embryos but only one heartbeat. Although this news was devastating to Sofia, her husband and other friends/family members did not understand her reaction and were not as sympathetic. At 20 and 26 weeks, Sofia experienced painful contractions and required hospitalization. At 37 weeks, she returned to the hospital after noticing swelling in her feet and having elevated blood pressure. Labor was induced and lasted 14 hours. Her son was born with liquid in his lungs, jaundice, and was initially unable to breathe on his own. He stayed in the NICU for 5 days. Sofia was discharged from the hospital 2 days before her son. One day after she was discharged, Sofia had to return to the hospital due to postpartum preeclampsia. Her blood pressure was 191/119. She remained in the hospital for 4 days under observation; her doctors were afraid she might suffer a stroke, aneuryism, or organ failure. During this time, she only saw her son once. Fearing for her life, Sofia did not receive comfort from her medical providers: “I just wanted someone to tell me I was going to be okay, and no one did. I thought I was going to die.” At the time of intake, Sofia met criteria for PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013), and all clusters were elevated. She reported that her symptoms of PTSD—for example, having repeated, unwanted, disturbing memories of the trauma; avoiding memories or thoughts related to the trauma; and feeling alert/on guard—have negatively interfered with her general satisfaction with life; overall level of functioning; and more specifically with her household chores/duties, relationships with friends and family, and fun and leisure activities.

5 Assessment

Sofia’s pretreatment intake evaluation included modules from the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2002) and the SCID for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997), and self-report measures, including the Dissociative Experiences Scale (DES), Beck Depression Inventory–II (BDI-II), State-Trait Anxiety Inventory (STAI), Impact of Events Scale (IES), and PTSD scales—Posttraumatic Stress Disorder Checklist for Civilians, DSM-5 (PCL5), and Posttraumatic Cognitions Inventory (PTCI).

The DES (Bernstein & Putnam, 1986) is a 28-item measure which assesses how often certain dissociative experiences occur (sample item: “Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something and they actually see themselves as if they were looking at another person. Indicate what percentage of the time this happens to you.”). Scores of 30 or higher are suggestive of a dissociative disorder or more severe psychopathology, which requires a higher level of care than brief trauma-focused therapy at an outpatient clinic.

The BDI-II (Beck, Steer, & Brown, 1996) is comprised of 21 items scored on a 0 to 3 scale, with higher total scores indicating higher levels of depressive symptoms. It is a widely used and well-validated measure of depression.

The STAI (Spielberger, 1983; Spielberger, Gorsuch, & Lushene, 1970) is divided into STAI State and STAI Trait, which are both 20 items each. State anxiety refers to how a respondent feels “right now, at this moment,” whereas trait anxiety targets how a respondent generally feels (e.g., “I am ‘calm, cool, and collected’,” “I worry too much over something that really doesn’t matter.”) Responses are rated on a 4-point Likert-type scale, ranging from 1 = not at all to 4 = very much so for the STAI State and from almost never to almost always for STAI Trait.

The IES (Horowitz, Wilner, & Alvarez, 1979) specifically targets two commonly reported categories of experiences in response to traumatic or stressful events, namely, intrusive ideas; images, feelings; or nightmares and avoidance of ideas, feelings, or situations. This 22-item questionnaire asks respondents to rate how distressing certain difficulties were, such as, “Other things kept making me think about [the trauma]” and “I avoided letting myself get upset when I thought about [the trauma] or was reminded of it.” Responses range from 0 = not at all distressing to 4 = extremely distressing.

The PCL5 (Blevins, Weathers, Davis, Witte, & Domino, 2015; Weathers, 2008) is a widely used self-report measure of PTSD symptoms. This 20-item questionnaire matches up with the symptom clusters indicated in the diagnosis of PTSD including reexperiencing, avoidance, negative thoughts/feelings, and trauma-related arousal. Responses, which range from 0 = not at all to 4 = extremely, indicate how often each problem has bothered the respondent in the past month.

The PTCI (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) consists of 33 statements in which respondents rate agreement on a 7-point Likert-type scale (1 = totally disagree to 7 = totally agree). Sample items include “The event happened because of the way I acted” and “My life has been destroyed by the trauma.” The scale yields a total score (the sum of the 33 items) as well as three subscales scores: negative cognitions about self (21 items), negative cognitions about the world (7 items), and self-blame statements (5 items). The three subscales are each summed and divided by the number of items on the subscale.

Clients who endorse active suicidal ideations, severe borderline personality disorder, or DES scores of 30 or higher, suggestive of a dissociative disorder, are referred out for a higher level of care. At the time of intake, Sofia denied any current active suicidal ideations, did not meet criteria for borderline personality disorder, and had a DES score of 19. Although Sofia had a previous suicide attempt at age of 10 years, her marriage and social support from her husband as well as the need to provide for her son mitigated this risk and allowed her to be accepted for treatment.

Per the results of the clinical interview and self-report assessments, Sofia met diagnostic criteria for PTSD, endorsing repeated, unwanted memories of the trauma, avoiding external reminders of the trauma, and feeling hyperalert/easily startled. She met criteria for MDD with a recurrent, severe episode, endorsing feelings of sadness, guilt, agitation, and fatigue, and for GAD, reporting symptoms of nervousness and restlessness and endorsing constant worries in many domains (her own health, her son’s health, finances, future natural disasters). She also met criteria for panic disorder with panic attacks, having experienced several panic attacks per week at the time of intake, and agoraphobia. Given her fear of experiencing a panic attack outside the home, Sofia often avoided going to certain crowded places where escape might be difficult (e.g., crowded restaurant, sitting in the middle row of a movie theater, grocery store, or busy parking lot). Sofia’s progress throughout treatment was tracked utilizing the BDI-II, STAI, IES, and PTSD scales at baseline; Sessions 3, 6, 9; and at 3 and 6 months after intake. She also completed a 3 month follow-up post termination. Total scores at each evaluation time point are listed in Table 1. In addition, during the active PE sessions, Sofia’s subjective distress was measured by the Subjective Units of Distress Scale (SUDS; see below for description). Sofia’s start, peak, and ending SUDS ratings during the active PE sessions are displayed in Table 2.

Table 1.

Progress During Treatment.

Therapy focus	Intake	Active PE (Sessions 3-14)				CBT (Sessions 15-19)
Session number	0	3	6	9	14	20
BDI-II	37	24	21	19	15	5
PCL5	63	42	32	25	34	12
STAI (State)	49	54	33	36	34	37
IES	56	46	29	20	34	12
PTCI total	167	133	129	116	131	51
Self	5.2	4.4	4.2	3.9	3.9	1.8
World	5.3	4.6	3.9	4.1	4.1	2.5
Self-blame	4	1.8	2.8	1.2	4.2	1

Note. PE = prolonged exposure; CBT = cognitive behavioral therapy; BDI-II = Beck Depression Inventory–II; PCL5 = Posttraumatic Stress Disorder Checklist for Civilians, DSM-5; DSM = Diagnostic and Statistical Manual of Mental Disorders; STAI = State-Trait Anxiety Inventory; IES = Impact of Events Scale; PTCI = Posttraumatic Cognitions Inventory.

Table 2.

SUDS Ratings Over Treatment.

	SUDS start	SUDS peak	SUDS end
Session
3	70	90	50
4	25	60	15
5	10	40	15
6	10	12	10
7	20	70	20
8	25	25	10
9	8	30	10
10	30	50	15
11	30	45	20
12	15	25	15
13	20	20	15
14	15	55	20

Note. SUDS = Subjective Units of Distress Scale.

The SUDS rating scale (Wolpe, 1990) ranges from 0 (no distress) to 100 (highest degree of distress imaginable). Clients are initially asked to come up with personal anchor points to compare distressing situations (e.g., “A SUDS of 25 for me is . . .”) and refer to this scale during exposure sessions. SUDS ratings were requested every 5 to 10 min during exposures.

6 Case Conceptualization

Given that PE has demonstrated effectiveness in lowering symptoms of PTSD as well as MDD, PE was elected as the most appropriate intervention for Sofia. At intake, Sofia reported that her most distressing trauma was the post partum preeclampsia, and thus, treatment focused primarily on processing this stressful event. Her traumatic experience at the hospital exacerbated her anxieties about her own health and her son’s health and served as a trigger for panic attacks. Therefore, engaging in both imaginal exposures (namely, reliving the experience of being in the emergency room) and in vivo exposures (e.g., driving by the hospital) were paramount to not only target her PTSD but also reduce symptoms of anxiety and the frequency of panic attacks.

As part of the PE intervention, clients are taught “Breathing Retraining” as a coping strategy to alleviate distress and anxiety evoked by the trauma (Foa, Hembree, & Dancu, 2002). This calming breath technique is also appropriate in other times of distress, including in vivo exposures and panic attacks.

Sofia grew up in a volatile household, where she was berated with insults, witnessed physical abuse, and struggled with depression and anxiety without help or support. Emotionally abused by her mother and largely ignored by her father, Sofia internalized the helpless core belief, “I am incompetent.” A rape at age of 16 years and enduring a natural disaster that destroyed her home contributed to the development and maintenance of the helpless core belief, “I am a victim.” As PE does not directly target core beliefs, treatment was supplemented with several sessions of CBT, whereby Sofia learned about automatic thoughts and how thoughts, emotions, and behaviors are interconnected. By identifying and challenging some of her negative automatic thoughts, Sofia could confront these core beliefs and strengthen her sense of self-efficacy.

7 Course of Treatment and Assessment of Progress

Therapist

Sofia’s therapist was a master-level, advanced graduate student clinician working toward a doctoral degree in clinical psychology at the University of Miami (UM), who had had been trained in both PE and CPT as a part of UM’s Trauma Treatment Program (TTP). The therapist had weekly supervision meetings with Gail Ironson, MD, PhD (licensed Physician and Board Certified Psychiatrist) and Blanche Freund, PhD (licensed Psychologist). Dr. Ironson and Dr. Freund created UM’s TTP over 20 years ago and have since co-facilitated and co-supervised the program. Both have extensive experience treating clients with trauma histories/PTSD using empirically supported treatments including CPT, PE, and eye movement desensitization and reprocessing (EMDR).

Course of Treatment

Over the course of approximately 7 months, Sofia received 21 sessions of individual psychotherapy (2 preparatory sessions, 12 active sessions of PE, 5 sessions of CBT, and 2 termination/relapse prevention sessions).

Sessions 1-2 (Preparatory Sessions)

The first session provided Sofia with an overview of the treatment program and a general rationale for exposure. This included an explanation of avoidance and how it maintains posttrauma reactions. Prolonged imaginal exposure and in vivo exposure were also reviewed in detail. A publicly available video demonstrating the techniques employed during PE was shown. The second part of this introductory session was focused on breathing retraining, which included slowing down breathing and repeating either “calm” or “relax” during exhalation. The patient was taught the calming breath and practiced it in session. She was provided a handout which reviewed the rationale for treatment and was asked to practice the calming breath each day for 10 min per day. Given her severe depression (BDI score = 37), Sofia was encouraged to see a psychiatrist to discuss psychopharmacologic treatment.

The second preparatory session focused on reviewing common reactions to trauma. Her symptoms of reexperiencing the trauma, being easily aroused, irritable, and having difficulty concentrating, were normalized. Other common reactions, including nightmares, emotional numbness, avoidance, distancing oneself from others, feeling down and depressed, and having disruptions in relationships, were also discussed. The concept of SUDS was introduced, and with the therapist, Sofia created a fear hierarchy of situations that she had been avoiding. This hierarchy helped in planning in vivo exposures for homework. She was encouraged to continue using the calming breath; however, Sofia reported that she did not find the calming breath useful. Progressive muscle relaxation (PMR) was employed during Session 2, which Sofia enjoyed and preferred over the calming breath. She agreed to practice PMR at home.

Sessions 3-14 (Active PE Sessions)

Before beginning the first imaginal exposure, the rationale for exposures was reviewed again, briefly. This explanation included a review of how repeated reliving helps to organize the memory and process the trauma and a clarification of the concept of habituation—that the more often and longer confrontations are done, the easier it will be. She experienced some anticipatory anxiety and fear, which was normalized by the therapist. She then successfully engaged in imaginal exposure for 60 min, repeating the story of monitoring her blood pressure post childbirth, reading the 191 systolic/119 diastolic, calling her doctor, being rushed to the hospital emergency room, and ultimately fearing for her life. She became especially emotional when discussing her feelings of loneliness, guilt for not being able to care for her son right after his birth, and fear that her organs would fail or she would have a stroke. She repeated the trauma experience four times, though was very resistant before repeating it a second time. With encouragement, she proceeded and successfully completed the exposure. Sofia was tearful during session. Her SUDS began at a 70, peaked at 90, and was at a 50 by the end of exposure. The therapist processed the exposure with Sofia. Following PMR, Sofia’s SUDS went down to a 40. She also mentioned she saw a psychiatrist and was prescribed 10 mg of Lexapro, which she had been taking daily for the past week.

Active PE Sessions 4-9 consisted of 45 min of imaginal exposure, with 20 min of postexposure processing of thoughts and feelings and 30 min of discussion regarding the in vivo homework assignment. Sofia’s in vivo hierarchy list and the SUDS associated with each activity are listed in Table 3. The hierarchy was first established in Session 2; it was utilized for homework assignments throughout treatment and later revisited during Session 12. Sofia was encouraged to describe the trauma in as much detail as possible. Her beginning, peak, and end SUDS ratings are listed in Table 2. In earlier sessions, her SUDS ratings also helped reflect how fully engaged Sofia was in the exposure. For example, as noted in Session 6, Sofia was preoccupied with difficulties at home and was not fully engaged in the exposure (starting SUDS: 10, peak SUDS: 20, ending SUDS: 10). This imaginal exposure was suspended to process the difficulties at home instead. Over the course of these PE sessions, Sofia was asked to engage in in vivo exposures. She successfully visited the mall and grocery store and drove past the hospital, without experiencing any panic attacks. By the end of the ninth PE session, Sofia noted that she was feeling much better and reported that it was getting easier to talk about the trauma. She even discussed the trauma with her husband, which was the first time in 2 years they had spoken in detail about what had happened and how it affected her. In addition to these in vivo exposures, the imaginal exposures were recorded in session, and Sofia was asked to listen to the imaginal exposure 2 to 3 times at home each week.

Table 3.

In Vivo Hierarchy.

Activity type	SUDS (Session 2)	SUDS (Session 12)
Going to the mall by myself	35	10
Going to the mall with my family	45	10
Visiting any hospital ER	70	15
Hearing about a difficult pregnancy	73	25
Looking at pictures or videos of twins	60	30
Hearing about postpartum preeclampsia	70	40
Visiting a noisy, crowded restaurant	80	60
Having my husband shuffle my to-do list or choose the order in which I complete daily tasks	100	70
Driving on the highway	100	50
Visiting the specific hospital I was rushed back to	100	80

Note. SUDS = Subjective Units of Distress Scale; ER = emergency room.

Active PE Sessions 10 to 14 were focused on one particular “hotspot” of the trauma or the most distressing part of the experience. Specifically, when Sofia recounted how she called her sister and asked for her help with caring for her son, her sister was very dismissive. She could not understand why Sofia was giving such specific directions (i.e., how her son needs a certain amount of sunlight per day, exactly when to feed him, where his blankets are located), and according to Sofia, her sister did not recognize the gravity of Sofia’s health condition. In all six prior PE sessions, this was the point at which Sofia would become particularly emotional. In the postexposure discussion, themes of justice and fairness emerged, as well as Sofia’s resentment toward her sister for not acknowledging the difficulty and danger of her post partum experience.

At Session 13, Sofia stated that she stopped taking Lexapro as it was reportedly not helping to alleviate her anxious thoughts and worries. She was encouraged to visit her psychiatrist to manage medication, though Sofia ended up medication-free for the remainder of therapeutic treatment. At the beginning of Session 14, Sofia filled out follow-up questionnaires to track progress. As noted in Table 1, symptoms of PTSD as recorded by the PCL5, IES, and PTCI slightly increased from her scores at Session 9. There are a few reasons that this elevation may have occurred. First, this could have been a result of eliminating the medication; second, it could have been triggered by engaging in some challenging in vivo exposures, including visiting a crowded restaurant and busy movie theater the week prior; finally, it could be the result of Sofia avoiding listening to the imaginal exposure hotspot at home.

Sessions 15 to 19 (CBT)

Sofia made considerable progress during the active PE sessions. She demonstrated an improved ability to talk about her trauma and increased self-confidence in her ability to complete in vivo exposures. Still, some symptoms of depression and anxiety persisted; therefore, the therapist elected to supplement treatment with elements of CBT. Sofia first learned about the CBT triangle or how thoughts, emotions, and behaviors influence and are influenced by one another. She demonstrated learning by filling out worksheets identifying her automatic thoughts and, in later sessions, identifying what thinking trap (i.e., mindreading, catastrophizing, and black/white thinking) was at work. Sessions focused on reviewing negative thoughts recorded on thought logs, identifying the associated thinking trap, and challenging the thought in session. In earlier Sessions (16-17), the therapist engaged in Socratic questioning, the upward arrow technique, and exploring the evidence to assist Sofia in thought challenging and thought restructuring. By the end of Session 19, Sofia could identify her maladaptive thought patterns with greater ease and effectively restructure them without the aid of the therapist. For example, she independently restructured the catastrophic thought: “My sister’s childbirth experience is going to be terrible and traumatic, and the baby might have health problems” to “My sister is pretty healthy and has had previous uncomplicated deliveries. Most women have normal deliveries.” In addition, she restructured the thought: “I forgot my son’s pacifier, therefore I’m a bad mom” to “I’m not a bad mom. I try my best to be there for my son in any way I can. Sometimes these things happen, and I’ll try to remember next time.” Finally, she challenged the thought: “If I drive on the highway, someone is going to hit me” by recognizing “I’ve only been hit once or twice in car accidents, where I was ultimately okay. I’ve driven many more times without getting hit than that.”

Sessions 20-21 (Termination/Relapse Prevention)

After Sofia completed her 6-month follow-up questionnaires, she voiced an interest in terminating therapy. Her therapist agreed with the timing, given that Sofia’s symptoms of PTSD and depression had remitted, and her anxiety and panic attacks had significantly reduced. More specifically, she reported that she no longer felt sad all the time or disappointed in herself. She endorsed getting pleasure from activities and feeling interested in socializing with others and making plans with family and friends. She endorsed improvements in her level of energy, sleep, and concentration. These improvements were noted by the 86% reduction in her BDI score (from a score of 37 to a score of 5). All symptom clusters of PTSD went down significantly, supported by her scores on the PCL5. Overall, her PCL score went from a 63 to a 12, demonstrating an 81% reduction. More specifically, Cluster B (reexperiencing) went from a 15 to a 3, an 80% reduction; Cluster C (avoidance) went from an 8 to a 1, an 88% reduction; Cluster D (negative thoughts or feelings) went from a 20 to a 2, a 90% reduction; and Cluster E (hyperarousal/reactivity) went from a 20 to a 6, a 70% reduction. Her IES score moved from a 56 to a 12, a 79% reduction, demonstrating that Sofia was significantly less distressed or bothered by intrusive ideas, images, feelings, or nightmares and was less avoidant of ideas, feelings, or situations that reminded her of the trauma. Finally, her PTCI score went from a 167 to a 51, which at first glance appears to be a 69% reduction, but because the items range from 1 to 7 (so the lowest possible score is 33), the true reduction in symptoms is 87%. Based on her responses to this questionnaire, Sofia reported that she did not feel inadequate or hopeless about her future; she disagreed with statements such as “If I think about the event, I will not be able to handle it” and “I used to be a happy person, but now I am always miserable.” At intake, she “very much” or “totally” agreed with these statements. Finally, although the reduction in anxiety (STAI) was not as dramatic, it was still substantial, 41.4% = ((49-20) - (37-20)/ (49-20)).

To prepare for termination, Sofia was provided with a self-therapy worksheet, which assessed the following areas: review of past week(s), review of homework, current problematic issues/situations, prediction of future problems, set new homework, and schedule next self-therapy appointment. Sofia also engaged in her two most-feared in vivo exposures, including driving on the highway at night for an hour and visiting the hospital she was treated in. She was praised for her dedication to treatment and provided an additional self-therapy worksheet to continue practicing the skills learned in therapy. Signs and symptoms of relapse along with how to contact the TTP in the future were reviewed.

Assessment of Progress

Sofia successfully completed treatment and is able to discuss the post partum trauma with minimal distress. She has gained self-confidence and tackled initially feared situations, including going to a musical and sitting in the middle of the row, driving on the highway, and visiting the emergency room of the hospital in which she was treated. She is less avoidant of social situations and has demonstrated proficiency in recognizing distorted thoughts on her own. She signed up to take two online college courses, a long-time goal of hers. She reported significant reduction in the frequency of panic attacks from multiple times per week to one every few months. She also demonstrated competence in coping with stressful situations, including use of the calming breath, grounding techniques, and PMR. Outcome monitoring via well-validated questionnaires confirmed substantial reductions in her scores for PTSD (based on the PCL5 and PTCI) and depression (based on the BDI-II). She no longer meets criteria for MDD, PTSD, or agoraphobia. Given these improvements and her motivation for treatment, Sofia’s overall prognosis is good.

8 Complicating Factors

Sofia presented to treatment with a complicated history inclusive of previous traumas: witnessing physical abuse from her mother toward her brother, a rape at age of 16 years, and living through a hurricane that destroyed her family mobile home. Her family history of bipolar and PTSD. Her mother, brother, and sister have a history of a suicide attempt; she herself attempted suicide at the age of 10 years by swallowing her mother’s sleeping pills. In addition, Sofia received little psychological and pharmacological intervention prior to intake. At baseline, she met criteria for PTSD, MDD, GAD, panic disorder, and agoraphobia. Despite these complicating factors, Sofia was dedicated to treatment and willing to engage in PE.

An additional complicating factor was Sofia’s decision to terminate pharmacological treatment herself. As previously noted, at Session 13, Sofia stopped taking Lexapro, because it was reportedly not helping alleviate her symptoms. As noted by her PTSD questionnaires at the following session, her PTSD symptoms initially rose following medication termination; however, these symptoms later remitted. Although Sofia was encouraged to revisit the psychiatrist and discuss medication management with him, she ultimately did not return to the psychiatrist and remained off medication for the duration of treatment.

9 Access and Barriers to Care

Sofia entered treatment unemployed, and following a recent hurricane, her husband also lost his job as his place of business was destroyed. Given these financial setbacks, the affordability of treatment was initially a concern. Fortunately, Sofia was able to receive a significant discount on the price of weekly treatment, and she committed to weekly attendance.

Second, at the start of treatment, Sofia feared and frequently avoided driving. Her husband drove her to many of her appointments early on in treatment. After engaging in therapy and practicing in vivo exposures, Sofia ultimately gained the self-confidence to drive herself to therapy.

10 Follow-Up

Several attempts by email and phone were made to contact her to obtain a 3 month follow-up (post-discharge) but were unsuccessful.

11 Treatment Implications of the Case

Sofia presented to treatment with a complicated history, inclusive of multiple diagnoses and several past traumas that were not directly targeted in previous therapy. Although PE has demonstrated effectiveness in treating PTSD in general, its usefulness in specifically treating postpartum PTSD has not been explored. Despite the complicated presentation, Sofia responded very well to PE, which directly targeted her postpartum preeclampsia. Sofia’s course of treatment demonstrates how PE can effectively reduce symptoms of PTSD, including reexperiencing the trauma, avoidance, and hyperarousal, and at the same time prepare a client to better learn and incorporate the tenets of CBT. After successfully engaging in both imaginal and in vivo exposures, Sofia’s symptoms of PTSD, anxiety, and panic attacks lessened. However, some symptoms of depression, particularly feelings of worthlessness and guilt, persisted, following exposure therapy. Adding several sessions of CBT helped improve Sofia’s confidence, thereby lessening feelings of worthlessness and guilt. Moreover, CBT provided Sofia with the necessary skills to challenge her desire to constantly be in control of any situation. Targeting these symptoms first helped with the later implementation of cognitive and behavioral skills to reduce residual symptoms. Notwithstanding these promising results, additional research is warranted to determine the effectiveness of augmenting PE with CBT to treat postpartum PTSD.

Prior case studies with women with psychological problems in the peri- and postpartum period have demonstrated successful symptom reduction, using a variety of techniques. For example, exposure therapy proved effective for a 25-year-old female with PTSD following a history of sexual traumas (Twohig & Donohue, 2007). Although the treatment proceeded during the pregnancy, the PTSD was from a series of events years prior to the pregnancy, and there was no pregnancy-related trauma (or any post partum-related trauma). Another approach, stress inoculation therapy, which includes elements of progressive muscle relaxation, deep breathing, guided imagery, and cognitive restructuring, reduced symptoms of PTSD in the case of a 27-year-old female who had emergency gynecological surgery 3 weeks post partum (Trzepacz & Luiselli, 2004). CBT that followed implementation of PE in the current study has also been successfully utilized in a young mother with postpartum depression (Ammerman et al., 2007). However, none of these used the Foa et al. (2002) PE approach in the context of a trauma during the peri- or post partum period.

12 Recommendations to Clinicians and Students

The current study augmented PE with CBT to treat symptoms of PTSD, anxiety, depression, panic disorder, and agoraphobia in a 28-year-old married Hispanic female following a life-threatening case of postpartum preeclampsia. To our knowledge, this is the first case report examining the utility of augmenting PE with CBT to treat postpartum PTSD. Prevalence of postpartum PTSD ranges from 1% to 30%, and important risk factors include past trauma and psychological problems, low social support, and traumatic birth experience (Grekin & Hara, 2014). Despite the identification of these risk factors, effective treatment for postpartum PTSD has not yet been established (Ayers et al., 2008). There is a clear need for efficacy research using large, multicenter trials to validate treatment recommendations for postpartum PTSD. Although the current study is limited as a single participant, the results are promising. Validated self-report measures indicate significant symptom reductions in depression and PTSD in particular, and the patient reported that panic attacks significantly diminished in frequency and severity. This case illustrates that continuous monitoring of symptoms both through questionnaires and patient self-report are essential and meaningful ways to track progress. Furthermore, despite Sofia’s comorbid presentation and history of multiple traumas, she responded well to this augmented treatment. It is important for clinicians to remain flexible in their approach and integrate or change treatment modalities, if warranted. This case serves as an excellent example of how, despite its intensity, PE can be effective and help prepare a client to better learn and implement CBT skills.

Footnotes

Acknowledgements

A special thanks to our client who gave permission to write about her case for a professional journal.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Samantha A. Reina

Author Biographies

Samantha A. Reina, MS, is currently an intern at the Bruce W. Carter Miami VA and sixth-year psychology doctoral student with clinical and research interests in health and rehabilitation psychology. Following graduation in May 2019, Samantha will continue her training as a postdoctoral fellow in Interprofessional Collaborative Care at the New Jersey VA.

Blanche Freund, PhD, is a lecturer and adjunct faculty in the Department of Psychology. She has conducted clinical research and therapy with trauma survivors since 1987. She has been the codirector of UM’s Trauma Treatment Program since 1995 and conducts training and supervision in Prolonged Exposure.

Gail Ironson, MD, PhD, is a professor of psychology and psychiatry and a board-certified psychiatrist. She has over 200 publications in the field of behavioral medicine applied to HIV/AIDS, cancer, cardiovascular disease, and the biological effects of trauma. She has directed the UM Trauma Treatment Program for more than 20 years.

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