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Hello, my name is Jay Monu, and today I will be presenting my oral comprehensive exam on prolonged exposure versus present centered therapy for post-traumatic stress disorder in adults.
Comparison of prolonged exposure and present centered therapy for PTSD treatment in adults, focusing on efficacy, guidelines, and NP roles.
Key Takeaways
- Prolonged exposure therapy is more effective than present centered therapy for reducing PTSD symptoms.
- Present centered therapy is a valid alternative when trauma-focused therapies are refused or not feasible.
- Nurse practitioners are essential in early PTSD detection, referral, and management of evidence-based treatments.
- Clinical practice guidelines consistently recommend PE as first-line treatment and PCT as second-line.
- Ongoing research is needed to optimize treatment protocols and expand telehealth delivery options.
Summary
- Jay Montague presents an oral comprehensive exam comparing prolonged exposure (PE) and present centered therapy (PCT) for PTSD in adults.
- Case study of a 29-year-old female veteran with PTSD highlights clinical presentation, assessment, and treatment initiation.
- PICO question focuses on effectiveness of PE versus PCT in reducing PTSD symptom severity over 12 weeks using CAPS 5.
- PTSD affects 3.6% of US adults annually with a large economic burden of $232.2 billion, emphasizing need for effective treatment.
- PE is a trauma-focused therapy recommended as first-line treatment by VA, DoD, APA, NICE, and IST guidelines; PCT is a non-trauma-focused second-line option.
- Systematic reviews and RCTs show PE has stronger outcomes than PCT, though PCT remains effective compared to waitlist controls.
- Nurse practitioners play a critical role in screening, diagnosis, referral, and coordinating evidence-based PTSD treatments.
- Research gaps include optimal dosage, treatment length, long-term follow-up, and telehealth delivery of therapies.
- Implementation recommendations prioritize PE with outcome evaluation via CAPS 5 and patient-centered shared decision-making.
- Quality improvement initiatives focus on screening, treatment pathways, reducing dropout rates, and telehealth adaptations aligned with NP competencies.
Chapters
- 00:00Introduction and Case Study
- 01:35PICO Question and Practice Problem
- 03:48Role of Nurse Practitioners in PTSD Care
- 05:35Evidence Review: Systematic Reviews and Meta-Analyses
- 07:51Randomized Controlled Trials Comparing PE and PCT
- 09:47Clinical Practice Guidelines and Recommendations
- 11:23Implementation and Outcome Evaluation
- 13:04Patient Preferences, Ethics, and Safety Considerations
- 17:07Quality Improvement and NP Competencies
Full Transcript — Download SRT & Markdown
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Let's begin with my case study related to AA. She's a 29-year-old married Air Force reservist and recent nursing school graduate who presented with anxiety and situational depressive symptoms secondary to job determination that now threatens her eligibility to
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sit for the ENLEX. She carries a history of PTSD and sexual violence in 2015, ongoing nightmares, avoidance, and emotional detachment. Assessment tools indicate moderate to severe anxiety of a GAD seven of 13 and mild depression of a PHQ9 scoring at 13 with intact cognition
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and good insight on mental status exam. AA's supportive marriage and academic accomplishments are strengths, while social withdrawal and career uncertainty pose challenges.
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She was diagnosed with adjustment disorder with mixed anxiety and depressed mood. Alongside PTSD, she started on sertraline 50 mg daily, hydroxyzine 25 mg PRN three times a day, and referred to CBT-based counseling with follow-up in 4 to 6 weeks. My PICO
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was derived from this case after selecting which type of referral was needed for her.
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My PICO question is: In adults aged 18 and older with primary diagnosis of PTSD, does prolonged exposure therapy compare with present centered therapy in reducing PTSD symptom severity measured by the clinician administered PTSD scale or CAPS 5 over the 12-week treatment
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period? Let's start by looking at the practice problem together. Post-traumatic stress disorder, also known as PTSD, affects approximately 3.6% of US adults annually. The economic burden is staggering at 232.2 billion per year when you account for direct health care costs, loss
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productivity, and disability payments. This project compares two psychotherapy approaches. Prolonged exposure, also known as PE, is a trauma-focused therapy involving imaginal and in vivo exposure to trauma memories and is recommended as first-line treatment by VA DoD 2023 and APA 2025
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guidelines. Present centered therapy, also known as PCT, is a non-trauma-focused therapy, helping patients manage daily challenges without directly processing their trauma. The nurse practitioner role here is vital as they are often the first contact for trauma symptoms screening, diagnosis,
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and referring to treatments like PE and PCT. This issue is significant for three reasons. First, the annual economic burden is huge at 232.2 billion, covering direct health care expenses, lost productivity and work, and disability payments. Effective and early detection and treatment of
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PTSD can substantially lower the long-term cost. Second, the prevalence is substantial. Approximately 3.6% to 6% of US adults meet DSM-5 criteria for PTSD in any given year. Certain populations are disproportionately affected, including veterans, first responders, and survivors of interpersonal violence. Many of these
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patients remain undiagnosed or receive suboptimal treatment. Third, the NP role is directly relevant by serving as primary care providers who administer screening tools like the PCL-5, coordinate CAPS 5 referrals for formal diagnosis, and manage the referral process to evidence-based
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treatments. The NP competencies emphasize that NPs must apply advanced assessment skills, synthesize evidence, and collaborate within interprofessional teams to optimize patient outcomes.
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Transitioning to the evidence-based practice and literature review section, I applied the hierarchy of evidence to identify the strongest studies addressing my PICO question. Level one evidence consists of systematic reviews and meta-analyses and randomized controlled trials. Level two evidence included
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individual RCTs. Level three evidence comes from clinical practice guidelines including the VA, APA, NICE, and ISTs, and one level five article. My search strategy was PICO guided using the Institute of Medicine framework, as search libraries using key terms and
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limited inclusion evidence of adults and publications within the past 5 years. This evidence table presents the study starting with level one data. Eel and Conto completed a level one meta-guideline reviewing 10 international clinical practice guidelines. PE and CPT
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ranked highest, rated first line by nine out of the 10 guidelines. PCT was rated second line by four of the guidelines.
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Belchure completed a level one Cochrane systematic review and meta-analysis of 12 studies with 1,837 participants. They found PCT was effective compared to the waitlist with a moderate effect size, confirming that while PCT is effective, PE demonstrated stronger outcomes.
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Troy conducted a level one systematic review and meta-analysis of 42 RCTs focused on complex trauma. The study found that CPT, PE, and phase-based TF-CBT had a large effect on PTSD, while PE, EMDR, and PCT showed moderate effects. Trauma-focused treatments outperformed present centered approaches in reducing PTSD and depression. The 2020 network meta-analysis by May Ru Ni Zuli was a level one network meta-analysis of 90 trials with 6,560 participants. The results indicated that PE was the most effective intervention,
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while PCT had a moderate standardized mean difference compared to the waitlist. Litz completed a level two RCT comparing adaptive disclosure enhanced to PCT in 174 post-9/11 veterans with PTSD related to traumatic loss and/or moral injury.
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This was the first individualized psychotherapy trial for military-related PTSD to demonstrate superiority over PCT on functioning outcomes. Schneer completed a level two RCT comparing PE to PCT in 284 female veterans and active duty service members. PE showed a small
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but significant advantage over PCT. These effects were consistent over time. FOA completed a level two RCT with 366 active duty military personnel across four arms: mass PE, spaced PE, PCT, and minimal contact control. Mass PE was not inferior to spaced PE. However, spaced PE
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was not specifically different from PCT. Thomas and Highlands completed a level two RCT, analyzed data from 284 female veterans and active duty service members. PE demonstrated faster symptom reduction per session than PCT. Findings identified increased PE sessions correlated with improved outcomes.
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Watkins reviewed and included 24 RCTs with 2,400 adults with PTSD. Despite being outdated, it showed PE was more effective than PCT for reducing PTSD symptoms with medium to large effect size. Important research gaps involve differences across populations, unclear optimal dosage and treatment length,
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limited long-term follow-up data, and a need for studies on telehealth delivery. This chart displays the ranking of psychological interventions for PTSD based on the meta-guideline review for 10 international clinical practice guidelines. Prolonged exposure and cognitive processing therapy are tied
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for first place with scores of 9.5 out of 10, making them the most consistently recommended first-line treatments worldwide. Present centered therapy ranks lower at four, indicating that although acknowledged as effective, it doesn't achieve the same results as
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the trauma-focused therapies. The VA DoD clinical practice guideline of 2023 strongly endorses PE as a primary treatment option. It conditionally suggests that PCT be an alternative for patients who refuse trauma-focused therapy. The APA guidelines for 2025 also recommend PE
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and CPT as first-line therapies but advise against PCT when trauma-focused options are accessible.
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The NICE guidelines from the UK published in 2018 recommend trauma-focused CBT, EMDR, or PE, considering PCT only if therapy is refused. Similarly, the 2018 ISTs guidelines list PE and CPT as first-line treatments with PCT as a
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second-line option. The consistent emphasis in these guidelines is notable. PE is widely accepted as primary treatment, whereas PCT is considered secondary. This distinction directly affects the NP's decisions regarding referrals. Now let's discuss the theoretical framework guiding my pro...
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second line option. The consistent emphasis in these guidelines is notable. PE is widely accepted as primary treatment whereas PCT is considered secondary. This distinction directly affects the MP's decisions regarding referrals. Now let's discuss the theoretical framework guiding my
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project. I chose the Iowa model revised of 2017. This framework is well suited for this project because it highlights clinical triggers as the initial step for evidence-based practice inquiry. The sevenstep process begins with the trigger. In our example, the practice
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problem is whether PE or PCT is more effective in treating PTSD in adults. Step two involves formulating the question using the Peacock framework.
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Our PICO question specifies the population intervention comparison outcome, and time frame. Step three involves evaluating the evidence using my evidence table from the S systematic reviews and RCTs.
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Step four considers whether the evidence supports changing practice. My evidence does support PE as a most effective treatment for PTSD compared to PCT.
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Step five focuses on implementation based on the evidence. We suggest that PE be used for the initial treatment for PTSD in adults. Step six is the outcome evaluation using CAPS 5 scores and dropout data. Finally, step seven is
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dissemination, applying the findings to MP practice at the point of care. The Iowa model was chosen because of the emphasis on the pilot testing and its feedback loop that supports continuous outcome evaluation.
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Let's now look at how we applied this framework. This table links each PICO element to the Iowa model steps. The practice problem is the trigger. Population intervention and comparison are addressed in formulate question and evaluate evidence step. I reviewed nine
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key studies finding consistent support for PE over PCT for PTSD treatment. Outcome and time guide the evaluate outcome step. Measuring CAP scores uh baseline 6 and 12 weeks. Implementation involves NPLE share decision making and referrals. Dissemination applies findings to MP practice protocols and
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referral guidelines. For ethical decision-m I applied the ANA code of ethics. Provision one emphasizes respecting human dignity, meaning honoring patient autonomy and PTSD treatment. While PE has a stronger evidence, patients can choose PCT if they prefer. Trauma survivors are
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vulnerable and the MP must acknowledge this. Provision two emphasizes that nurses primary duty is to the patient.
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When recommending PE, the MP must weigh the stronger evidence with the patients preferences and readiness, providing accurate info on PE PC and PCT effectiveness, including the higher dropout rates and the real efficacy.
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Informed consent should cover outcomes, side effects, and alternatives. It's about what's best for the individual, not just the evidence.
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Provision three safeguards patients rights, including self-determination. Patients can refuse PE and choose PCT, which NPs must respect. Informed consent should clearly state realistic expectations for both treatments, including temporary distress during PE.
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Provision 4 covers authority over accountability. The MP must work within their scope, stay proficient in CAPS 5 assessments, and refer to qualified therapist.
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Cultural sensitivity is vital for ethical PTSD treatments as cultural influences affect patients disclosure, helpseeking behaviors, and therapy participation. Nurse practitioners should practice cultural humility, recognizing each patient has unique cultural backgrounds, values, and beliefs about mental health. Language barriers can affect informed consents
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and therapeutic bonds. When working with diverse groups, the MP must ensure that patients understand the distinction between PE and PCT in the preferred language. Ethically, the NP commits to beneficence non-maleficence and autonomy, focusing on patients well-being, preventing harm, and
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respecting their informed choices. They also aim to counter implicit bias that could skew recommendations based on their assumption instead of evidence in patients preference.
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The use of technology is increasingly important in PTSD treatment. Tellahalth has demonstrated effectiveness for delivery both PE and PCT. Tellahalth expands access especially for rural, underserved or mobility challenged individuals. PCT suits tellahalth well, focusing on the present and making it a
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convenient option. Important gaps still remain, including limited research on long-term tellahalth PE outcomes. There's a need for standardized platforms supporting PE and PCT protocols for streamlining process.
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Mobile apps could support between session homeworks and AI screening tools might aid PTSD identification and primary care. All technologies must comply with HIPPA to ensure safety and confidentiality.
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Beyond tellaalth health IT includes electronic health records, patient engagement tools and regulation compliance. Integrating EHRs standardizes CAPS 5 scoring and tracks patient outcomes. Clinical decision supports can prompt PTSD screening with PCL5s during primary care visits. Patient engagement tools include mobile apps for trauma
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diaries and exposure homework. psycho educational videos for informed consents, patient portals for scheduling and progress monitoring and wearable devices that collect psychological data like heart rate variability.
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All technology used must adhere to HIPPA standards for health information and furpa for educational data. The NP is responsible for assessing technologies and communication platforms based on quality of care, accountability, ethics, and cost effectiveness in line with the
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NPF competencies 8.1L. Effective PTSD treatment depends on team-based collaboration with specific roles at each care level. As a future MP, understanding these roles is helpful. Psychiatrists handle medication for core mooridities like depression, anxiety and insomnia while psychologists or therapists provide PE or PCT
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maintaining treatment fidelity under supervision. The primary care NP screens with PCL5s handling CAPS fives referrals and overseeing the care. The social worker links patients to community resources. The peer specialist uses personal experiences to engage patients.
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The NPF competency states that the MP should communicate in ways that foster a partnership approach to quality care and advocate for a patient as part of the health care team.
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Effective collaboration relies on communication and shared decision making involving the patient, the MP and the therapist. Regular team meetings and case discussions keep all aligned while clear communication about roles prevent duplication and ensure comprehensive care. All team members should use
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trauma-informed communication to prevent retraumatizing patients. Motivational interviewing effectively engages ambivate patients. The patient remains central influencing treatment preferences. The MP manages care coordination like screening, diagnosis, and referrals. The therapist delivers treatment while the psychiatrist manages medication. The health system provides
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resources, training, and community organization. Patient safety is crucial when managing PTSD. The do no harm principle requires screening for suicidality with validated tools like the Colombia's suicide severity rating scale before starting PE. Informed consent should mention potential temporary distress during
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exposure sessions. Patients need to understand that PE involves confronting trauma which may temporarily increase anxiety before improving. Safety planning is essential for at risk patients. During sessions, therapists would monitor for emotional disregulation.
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Implementing safety protocols in practice settings should align with NPF competencies. Ensuring quality is essential for safety. Key indicators include treatment completion rates, a significant CAPS 5 reduction is defined as a drop of 10 or more points and overall trends of using
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PCL5s. My QI plan involves standardizing PCL5 screening in primary care, developing a referral pathway, tracking CAPS 5 outcomes, monitoring dropout rates, and holding quarterly interdisciplinary reviews of outcomes. The plan do study act cycle directs the implementation process. Initially creating the
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screening protocol, next testing it in the primary care clinics for about 3 months, then evaluating the outcome data. Finally, improving and expanding the protocol according to the results.
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Person- centered care has four principles. Patient preferences with shared decision-m between PE and PCT. A holistic approach considering physical, psychological, social, and spiritual aspects. attention to vulnerable populations like veterans and minorities and traumainformed communication strategies. The care plan begins by
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evaluating the patients readiness for trauma focused treatment and checking for core morbidities. Treatment choices depend on the patients preferences and readiness. Progress is monitored using CAPS 5 at three three points, KCL5 at each session, satisfaction surveys, and dropout tracking, including
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re-engagement enforcement. Choosing between PE and PCT depends on the evidence. Studies shown PE outperforms PCT and is recommended first line in 10 guidelines. PE also results in greater CAPS 5 score reductions.
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Belshire indicated that PCT is effective compared to weight lists with a moderate effect size. The meta analysis showed a significant standardized mean difference and a higher completion rate making a beneficial option for patients preferring non-trauma focused therapies.
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Person centered care matches patients with appropriate treatments. The best PE candidate is motivated, emotionally stable, medication compliant, and is ready for homework. PCT is for those not wanting traumatic processing and focuses on the present, often preparing patients for future PE. The NP should use
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judgment and shared decision-m to find the best treatment, recognizing that the strongest evidence isn't always ideal for every patient.
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The impact of person centered care on the advanced nursing role is significant. It involves a thorough PTSD assessment with CAPS 5 considering social determinance of health. Diagnosis is based on the DSM5 standards for primary and differential diagnosis.
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Communication uses motivational interviewing and traumainformed approaches to engage patients in shared decision-m care planning creates a mutual mutually accepted coste effective evidence-based plan reflected to patients values.
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Outcome evaluation reviews results through evidence-based intervention and updated plans accordingly. Holistic care emphasizes confidentiality, privacy, comfort, emotional support, mutual trust, and respect as outlined in the NPF competency.
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Leadership and quality improvement in PTSD treatment should exemplify transformational leadership by showcasing evidence-based practices, advocating for PE through staff training, and fostering a culture of ongoing improvement. Innovation and change involves adapting new practices, identifying strategies for transformation, improving leadership
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skills, and recognizing the MP role of policy modifications. Systembased practices applies knowledge across the care continuum. Consider cost effectiveness, improve system efficiency, and engage in professional organizations to implement new knowledge.
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The MP should understand the legislative and regulatory framework that governs practice, including state scope of practice laws, ANA standards, VA guidelines, mental health parity laws, and HIPPO regulations.
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NP advocacy priorities encompass increasing availability of physical examinations and primary cares, backing mental health parity laws, advocating for NP scope of practice to include PTSD screening and referrals, combating stigmas via communication education initiatives, and funding training programs for trauma focused therapies.
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QI initiatives involve implementing PCL5 screenings, creating a treatment pathway algorithm, monitoring CAPS 5 results quarterly, decreasing PE dropout rates through better preparation, testing teleaalth PE delivery, and suggesting evidence-based QI initiatives align with NPF competencies.
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This table details the QI methodology along with specific targets for each component. It aims for screening over 90% of atrisisk patients using the PCL5 referring targets including over 85% of the appropriate matches between the patients and treatment types. Treatment
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completion goals are set at more than 70% for PE and over 80% for PCT following VA guidelines. Symptom reduction targets a minimum decrease of 10 points on the caps five. Patient satisfaction scores should reach at least four out of five.
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All outcome data will be recorded in the EHR system and reviewed quarterly by the interdisiplinary team. Quality metrics will be assessed against national benchmarks and results will be shared through the staff education sessions and updated to protocols.
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Key findings are that PE has level one evidence showing it's superior to PCT and it's ranked as a first-line treatment in 10 international guidelines. PCT remains effective compared to weight lists and suits patients not ready for trauma therapy.
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The Iowa model guides its implementation. Person centered care emphasizes shared decision making, cultural awareness and assessments with technology like teleaalth and EHR. Broadening access collaboration among healthcare professionals improve outcomes.
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Standardized screening and tracking systems support quality improvements. NPs play a vital role in screening, diagnosing, coordinating care and patient advocacy.
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Nurse practitioners should incorporate PCL5 screening in primary care, use CAP 5 for diagnosis, engage in shared decisionmaking, establish referral pathways, track outcomes with validated tools, and include teleaalth. Future direction involves researching long-term outcomes, optimizing PE doses, expanding teleaalth, training MPs and referrals,
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advocating policy reforms, and adopting screening protocols.
Topics:PTSDprolonged exposure therapypresent centered therapytrauma-focused therapynurse practitionerCBTclinical practice guidelinesmental healthveteransevidence-based practice
