Edna B Foa

University of Pennsylvania | UP · Department of Psychiatry

Prolonged exposure therapy (PE) is a well‐established first‐line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence ba...

Exposure therapy is the gold-standard treatment approach for pathological anxiety. This therapeutic approach builds on principles of extinction training from traditional fear conditioning and extinction protocols. In this chapter, we discuss principles of exposure therapy in the clinic and the laboratory experimental results that guide our decision...

Objective: In posttraumatic stress disorder (PTSD), the assumption of the equipotentiality of traumas ignores potentially unique contexts and consequences of different traumas. Accordingly, Stein et al. (2012) developed a reliable typing scheme in which assessors categorized descriptions of traumatic events into six “types”: life threat to self (LT...

Prolonged exposure (PE) is an empirically supported treatment for posttraumatic stress disorder (PTSD). The current study examined multiple facilitators and indicators of emotional processing to identify key predictors of outcome in PE using observational coding methods. Participants were 42 adults with PTSD who received PE. Video recordings of ses...

Prolonged exposure therapy (PE) is an evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Previous research suggests that postworkshop consultation is important for successful implementation. However, little is known about how consultation may relate to EBP adoption or pat...

Exposure and response prevention (EX/RP) is a recommended psychotherapy for obsessive-compulsive disorder (OCD). Yet, not all patients benefit equally from EX/RP. Prior studies have examined EX/RP predictors by predicting endpoint symptoms and/or pre-post symptom change, rather than accounting for trajectories of symptom change across treatment. We...

Exposure and response prevention (EX/RP) is a recommended psychotherapy for obsessive-compulsive disorder (OCD). Yet, not all patients benefit equally from EX/RP. Prior studies have examined EX/RP predictors by predicting endpoint symptoms and/or pre-post symptom change, rather than accounting for trajectories of symptom change across treatment. We...

Importance: Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). Objective: To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. Design, setting, and participants: This randomized clinical trial was conducted among...

Background This study aimed to examine the psychometric properties of reliability and validity of OCI-CV in a non-clinical sample of Malaysian children and adolescents. Method Participants of school-age and adolescent students from Klang Valley School completed the 21-item Malay OCI-CV using Google Form. OCI-CV English version was translated backw...

Background Several efficacious psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) are available; however, the comparative effectiveness of these treatments represents a major gap in the literature. The proposed study will compare the effectiveness of two leading PTSD treatments – Prolonged Exposure (PE) therapy an...

Preliminary evidence shows that brief, condensed imaginal exposure only interventions can be effective in the treatment of PTSD, but we need to understand its mechanisms of action. Consistent with extinction learning and retrieval processes, the present study examined whether a pattern of between-session distress reduction observed during standard...

Prolonged exposure (PE) is an efficacious and effective treatment for PTSD that has been studied extensively and disseminated around the world. PE is based on emotional processing theory (EPT; Foa and Kozak, Anxiety and the anxiety disorders, Erlbaum, 1985; Foa and Kozak, Psychological Bulletin, 99, 20–35, 1986), an influential theory of pathologic...

Objective: Prolonged exposure (PE) therapy is a first-line posttraumatic stress disorder (PTSD) treatment, but the manualized 90-min session format constitutes a barrier to adopting PE in most settings because they use 60-min sessions for scheduling and billing. We examined whether 60-min PE sessions were as effective and efficient as 90-min PE se...

Objective Based on feedback received during post-training consultation within a Prolonged Exposure (PE) implementation initiative, additional assessment training was added to help community providers identify patients who met criteria for posttraumatic stress disorder (PTSD) symptom severity and were considered appropriate for PTSD treatment. The c...

Until the mid-1960s, obsessive-compulsive disorder (OCD) was considered to be treatment-resistant, as both psychodynamic psychotherapy and medication had been unsuccessful in significantly reducing OCD symptoms. The first real breakthrough came in 1966 with the introduction of exposure and ritual prevention. This paper will discuss the cognitive be...

Reports an error in "The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder" by Carmen P. McLean, Edna B. Foa, Katherine A. Dondanville, Christopher K. Haddock, Madeleine L. Miller, Sheila A. M. Rauch, Jeffery S. Yarvis, Edward C. Wright, Brittany N. Hall-Clark, Brooke A. Fina, Brett T. Litz,...

Irritability, angry outbursts, and aggression are common among individuals with posttraumatic stress disorder (PTSD). Although aggression can be a problem among many individuals with PTSD, research suggests that the relationship between PTSD and aggression might be particularly relevant among military/veteran populations as compared to civilians. T...

Objective: Web-based prolonged exposure therapy (Web-PE) has potential to increase the reach of effective posttraumatic stress disorder (PTSD) treatment. While there is initial support for the efficacy of Web-PE, no studies have examined the perceptions and experiences of participants receiving PE in this novel, Web based format. Method: We used a...

Importance: Serotonin reuptake inhibitors (SRIs) are the only medications approved for obsessive-compulsive disorder (OCD), yet most patients taking SRIs exhibit significant symptoms. Adding exposure/response prevention (EX/RP) therapy improves symptoms, but it is unknown whether patients maintain wellness after discontinuing SRIs. Objective: To...

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in...

Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT cour...

Objective: Comorbidity between posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is common, and both are associated with cognitive dysfunction. However, few studies examine the impact of cognitive deficits on treatment outcomes. Here, we leverage data from a randomized clinical trial of integrated versus phased psychotherapy f...

Objective Previous research with civilian populations has found strong associations between fibromyalgia (FM) and posttraumatic stress disorder (PTSD). We undertook this study to investigate the prevalence of FM in military service members with and without PTSD. Methods Participants were active duty military personnel recruited into either an epid...

Objective: Failing to account for temporal dynamics can hinder our understanding of suicidal ideation and the potential mechanisms underlying increased risk for suicide death and suicide attempts associated with posttraumatic stress disorder (PTSD). To address these limitations, this study used an analytic approach based on Dynamical Systems Theor...

Background The availability of psychometrically sound instruments for the assessment of Post-Traumatic Stress Disorder (PTSD) is indispensable for clinical and scientific work with individuals suffering from trauma-related distress. Objective The aim of the present study was to translate the Post-Traumatic Diagnostic Scale for DSM-5 (PDS-5) into G...

Fluctuations of endogenous estrogen modulates fear extinction, but the influence of exogenous estradiol is less studied. Moreover, little focus has been placed on the impact of estradiol on broad network connectivity beyond the fear extinction circuit. Here, we examined the effect of acute exogenous estradiol administration on fear extinction-induc...

Childhood is a developmental period associated with high risk of posttraumatic stress disorder (PTSD). Available validated pencil-and-paper diagnostic tools can be difficult for younger children to engage with given format and length. This study investigated psychometric properties of a briefer, more interactive game version of the Child PTSD Sympt...

Prior work has shown a number of similarities between obsessive-compulsive disorder (OCD) and eating disorders such as perfectionism and depressive symptoms. However, distress and impairment due to eating pathology are also highly comorbid with other disorders, which brings into question whether the relationship with eating pathology is unique to O...

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid con...

Although prolonged exposure (PE) has been identified as a first-line treatment for posttraumatic stress disorder (PTSD), research has found that military service members and veterans have smaller reductions in symptom severity compared to civilians. The nature of trauma in a deployed combat setting and the unique complexities of military culture ha...

Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patien...

Prolonged Exposure (PE) is a highly effective treatment for posttraumatic stress disorder (PTSD) across a variety of delivery formats and samples. However, for military service members, the treatment tends to be less effective than for civilians. One explanation for the reduced response to PE in military service members is the frequency, intensity,...

Objectives Several recent studies have demonstrated that posttraumatic stress disorder (PTSD) and insomnia treatments are associated with significant reductions in suicidal ideation (SI) among service members. However, few investigations have evaluated the manner in which suicide risk changes over time among military personnel receiving PTSD or ins...

Objective: Web-based treatments address many of the logistical and stigma-related barriers to in-person behavioral health care. Prior studies of web-based treatments for posttraumatic stress disorder (PTSD) did not employ gold-standard treatments and have not compared to in-person therapy. Method: We compared a web version of Prolonged Exposure...

The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population's level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (...

Background: Prolonged exposure therapy (PE) is an evidence-based treatment for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Standard workshop training in PE may not be sufficient to alter provider behavior, but post-workshop consultation requires significant resources. Therefore, it is important to dete...

Case management plays a critical role in the Prolonged Exposure-Intensive Outpatient Program (PE-IOP) model. This chapter presents the logistics and rationale for case management as used in PE-IOP. The goal of case management is to provide necessary logistics to help the patient maximize therapeutic benefit from the PE-IOP program. Case management...

This chapter presents key assessment issues and recommendations to assist in patient selection and examination of response across the prolonged exposure-intensive outpatient (PE-IOP) treatment program. The authors discuss key issues including dissociation, suicide and self-harm risk, anger, moral injury, complex trauma, personality disorder, guilt,...

Trauma can leave a lasting impact on survivors. Some survivors are haunted by intrusive memories; avoid people, places, and situations related to the trauma; and feel constantly on edge due to posttraumatic stress disorder (PTSD) and related posttrauma reactions. Effective treatment can help survivors suffering with PTSD to process the trauma and n...

This chapter presents the foundations for prolonged exposure (PE) therapy as they have been developed in emotional processing theory to immerse the provider in theory that will guide all decisions during PE, whether they are using the intensive outpatient program (PE-IOP) in this manual or another model (e.g., PE-Primary Care, or standard PE). The...

This chapter presents in-depth details of how to implement the exposure component of the Prolonged Exposure-Intensive Outpatient Program (PE-IOP), including places where variation is acceptable and why. The authors present the logistics and rationale for individual sessions that include imaginal exposure and individualized trauma emotional processi...

In addition to the core of prolonged exposure in the Prolonged Exposure-Intensive Outpatient Program (PE-IOP), the program also includes integrative interventions designed to encourage positive coping, wellness, and maintenance of gains from PE-IOP. These integrative interventions can vary based on availability, cost, patient population, etc. While...

This therapist guide presents the scaffold and structure for the Prolonged Exposure-Intensive Outpatient Program (PE-IOP). The program is focused on exposure as provided through individual imaginal exposure and group in vivo exposure. The format presented is based primarily on the model used in the Emory Healthcare Veterans Program (EHVP), but this...

This chapter presents how all the pieces of the Prolonged Exposure-Intensive Outpatient Program (PE-IOP) fit together to form a program. The authors discuss areas for variations and ways to improve efficiency. Each day of the PE-IOP program is described, with each component noted and the detailed specifics outlined. Suggested time markers for sessi...

This chapter presents the rationale for why Prolonged Exposure for Intensive Outpatient Programs (PE-IOP) was created through an examination of some of the barriers to care that may appear in traditional outpatient psychotherapy for posttraumatic stress disorder (PTSD). Evidence for efficacy and effectiveness of PE-IOP for PTSD and related issues a...

Increasing research has implicated rumination in the development and maintenance in many types of psychopathology, including anxiety-related disorders. A few studies have explored the impact of rumination during cognitive-behavioral therapy (CBT) for anxiety-related disorders (which rely heavily on exposure-based interventions), with mixed results....

Background: Effective treatments for posttraumatic stress disorder (PTSD) (e.g., prolonged exposure (PE); cognitive processing therapy (CPT)) exist and are widely adopted by the Departments of Veterans Affairs (VA) and Defense (DoD). Unfortunately, dropout from these treatments regularly exceeds 30%. However, in a recent survey of patients who dro...

Study Objective To examine sleep disorder symptom reports at baseline and post-treatment in a sample of active duty U.S. Army Soldiers receiving treatment for posttraumatic stress disorder (PTSD). Explore sleep-related predictors of outcomes. Methods Sleep was evaluated in 128 participants in a parent randomized clinical trial comparing Spaced for...

Background Effective treatments for posttraumatic stress disorder (PTSD) (e.g., Prolonged Exposure (PE); Cognitive Processing Therapy (CPT)) exist and are widely adopted by the Departments of Veterans Affairs (VA) and Defense (DoD). Unfortunately, dropout from these treatments regularly exceeds 30%. However, in a recent survey of patients who dropp...

Aggressive behavior is prevalent among veterans of post-9/11 conflicts who have posttraumatic stress disorder (PTSD). However, little is known about whether PTSD treatments reduce aggression, or the direction of the association between changes in PTSD symptoms and aggression in the context of PTSD treatment. We combined data from three clinical tri...

Objective Compared to smokers without posttraumatic stress disorders (PTSD), smokers with PTSD smoke more heavily and are less successful in quitting smoking. However, limited research has examined the cognitive pathways underlying this heightened comorbidity. The current study is the first to simultaneously model the cross-sectional and lagged rel...

For many decades, the U.S. military's general operational guideline has been to limit the use of trauma-focused treatments for combat and operational stress reactions in military service members until they have returned from deployment. Recently, published clinical trials have documented that active duty military personnel with combat-related postt...

The accumulating evidence regarding the impact of estradiol on learning and memory synergized studies to examine its influence on enhancing animal’s ability to quell fear and anxiety. In this review, we first provide a foundational platform regarding the impact of estradiol on cellular mechanisms of learning and memory and review recent advances fr...

Objective: Recent clinical practice guidelines recommend the delivery of evidence-based psychotherapies for both substance use disorder (SUD) and posttraumatic stress disorder (PTSD) within the same treatment episode for patients with SUD/PTSD comorbidity. This randomized clinical trial evaluated the comparative effectiveness of integrating versus...

Objective: We evaluated patterns and predictors of change from three efficacy trials of trauma-focused cognitive-behavioral treatments (TF-CBT) among service members (N = 702; mean age = 32.88; 89.4% male; 79.8% non-Hispanic/Latino). Rates of clinically significant change were also compared with other trials. Method: The trials were conducted in...

Despite considerable data from randomized controlled trials supporting use of behavioral therapies for anxiety disorders and anxiety-related disorders, there is a relative scarcity of data demonstrating that such findings are generalizable to patients in nonresearch settings, and a lack of standardized repeated outcome measurement in such settings....

Not every trauma survivor needs a trauma-focused treatment like prolonged exposure (PE). Many studies have shown that natural recovery works very well for many people who experience a traumatic event. In fact, posttraumatic stress disorder (PTSD) symptoms and other trauma reactions are very common and happen for almost everyone right after a trauma...

In Session 2, the patient will learn about common reactions to trauma. He or She will begin to construct a list of situations they have been avoiding (called the In Vivo Exposure Hierarchy). In order to find out how much discomfort or anxiety certain situations provoke, the patient and the therapist will use the S ubjective U nits of D iscomfort S...

In this final session, the patient reviews the skills learned in the treatment program and looks at his or her overall progress. The patient is encouraged to very deliberately keep practicing the skills learned in therapy over the next several months (or as long as necessary), and, if they run into problems, they are advised to call the therapist f...

Even with all of the authors’ experience working with survivors of trauma with this treatment, and even with all of the hard work of patients and therapists, sometimes it is difficult for trauma survivors to get all they can out of prolonged exposure (PE) therapy. This chapter discusses common problems that may interfere with treatment and provides...

This therapist guide of prolonged exposure (PE) treatment is accompanied by the patient workbook, Reclaiming Your Life from a Traumatic Experience. The treatment and manuals are designed for use by a therapist who is familiar with cognitive behavioral therapy (CBT) and who has undergone an intensive training workshop for prolonged exposure by exper...

This session instructs the therapist on how to interactively present to the patient “common reactions to trauma,” an educational discussion that describes and validates the patient’s experience of PTSD symptoms, associated problems, and relationships among these experiences. Hope is instilled by helping the patient realize that many of his distress...

Foundations of prolonged exposure (PE) include (1) education about common reactions to trauma, what maintains trauma-related symptoms, and how PE reduces posttraumatic stress disorder (PTSD) symptoms; (2) repeated in vivo confrontation with situations, people, or objects that the patient is avoiding because they are trauma-related and cause emotion...

In Session 1, the patient learns about the overall treatment program and the procedures that will be used, including both imaginal exposure (reliving the trauma in imagination) and in vivo exposure (reexperiencing the trauma situation in real life). The patient will complete the Trauma Interview with the therapist and learn breathing retraining. Fi...

Up to this point, each time the patient has done an imaginal exposure, he or she has described the entire memory of what happened from the beginning to the end of the trauma. When the patient reaches the point in treatment of experiencing a decrease in anxiety and distress, at least with some of the relatively less disturbing parts of the memory, t...

This workbook, written for patients, is part of a brief cognitive behavioral therapy (CBT) program for individuals who are diagnosed with posttraumatic stress disorder (PTSD) or who manifest PTSD symptoms that cause distress and/or dysfunction following various types of trauma. The overall aim of the treatment is to help trauma survivors emotionall...

In the beginning of this first PE session, the therapist presents the patient with an overall rationale for PE and describes the main tools of the therapy: imaginal exposure and in vivo exposure. The therapist uses the Trauma Interview to collect general information about the immediate presenting problems, the patient’s functioning, the traumatic e...

Beginning around Session 5 or 6, emotional processing of the trauma memories can be made more efficient by having the patient focus primarily or exclusively on the most currently distressing parts of the trauma, which the authors term the “hot spots.” The therapist helps the patient identify his hot spots and then select one to begin the imaginal e...

Even with a foundation of strong therapeutic alliance and a clear rationale for treatment that the patient understands and accepts, and even when the therapist has followed the procedures described in the previous chapters, sometimes the patient does not seem to improve as much as we would expect. Common obstacles to the expected decreases in postt...

Imaginal exposure, or revisiting the trauma memory in the patient’s imagination, is a procedure in which the patient is asked to go over the traumatic event while saying it out loud repeatedly, in the present tense. In Session 3, the patient will do his or her first imaginal exposure to the trauma memory, followed by processing this experience with...

This session presents imaginal exposure, or revisiting the trauma memory in imagery, a procedure in which the patient is asked to visualize and emotionally connect with the traumatic memory while recounting the experience aloud, in the present tense. The standard procedure is designed to (1) enhance the patient’s ability to access the salient aspec...

The authors begin this chapter by looking at who a good candidate for prolonged exposure (PE) therapy is; not every trauma survivor needs a trauma-focused treatment like PE. It is important to have as part of the assessment process or prior to start of PE, one or two preparation sessions that include reviewing the reasons that the client wants to r...

This final session reviews what the patient has learned in the course of prolonged exposure (PE), what has changed or improved, and what the patient needs to continue to do. Also reviewed are concepts (e.g., facing rather than avoiding trauma memories and reminders) and skills the patient has learned. The therapist prepares the patient for the like...

The current study examined the role of trauma‐related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military person...

Objective: Numerous researchers have suggested that certain coping styles (e.g., maladaptive cognitive coping strategies) interfere with recovery from traumatic experiences and contribute to the onset/maintenance of posttraumatic stress disorder (PTSD). Further, given that individuals with PTSD have a high rate of smoking (e.g., Mahaffey et al., 2...

Background: Evidence-based treatments for posttraumatic stress disorder (PTSD) are associated with reduction in suicidal ideation (SI), yet the mechanisms underlying this reduction are unclear. The current study investigated improvements in PTSD, depression, and social support as potential mediators of the change in SI over time. Method: Partici...

Objective: Adolescents with posttraumatic stress disorder (PTSD) are at higher risk for suicide compared to adolescents without PTSD. This study aimed to explore whether PTSD treatment reduces suicidal ideation in adolescents and whether the degree of reduction in PTSD was associated with reduction in suicidal ideation. Methods: Adolescent femal...

The efficacy of prolonged exposure (PE) on suicide ideation (SI) as a secondary outcome among individuals with posttraumatic stress disorder (PTSD) is unclear. The purpose of this study was to compare the efficacy of PE in two formats (spaced, S-PE, 10 sessions over 8 weeks, and massed, M-PE, 10 sessions over 2 weeks) to Present Centered Therapy (P...

Trauma-related cognitions about the self and the world have been identified as a mediator of posttraumatic stress disorder (PTSD) change during prolonged exposure (PE) therapy. However, the extent to which negative cognitions mediate PTSD change in other PTSD treatments is unclear. In addition, previous studies have not tested alternate mediators o...

Prolonged exposure therapy (PE) is a highly efficacious and effective treatment for posttraumatic stress disorder (PTSD). In addition to reducing PTSD symptoms, PE ameliorates a wide-variety of related symptoms, including anxiety, depression, functional impairment, mild suicidal ideation, and anger. Furthermore, PE is effective in patients with com...

Dropout from first-line posttraumatic stress disorder (PTSD) treatments is a significant problem. We reported rates and predictors of attendance and dropout in three clinical trials of evidence-based PTSD treatments in military service members (N = 557). Service members attended 81.0% of treatment sessions and 30.7% dropped out. Individually delive...

Negative cognitions about oneself, others, and the world are central to the development and maintenance of posttraumatic stress disorder (PTSD). We provide a comprehensive review of the literature examining the change in post-trauma negative cognitions in PTSD treatments. We explore the association between change in cognitions and change in PTSD sy...

The Peri- & Post- Traumatic Emotions Questionnaire. Feel free to use in your research.

The Peritraumatic Emotions Questionnaire (Peri‐TEQ) and Posttraumatic Emotions Questionnaire (Post‐TEQ) are self‐report measures of emotions experienced during and after a traumatic event, respectively. The factor structure and psychometric properties of the Peri‐ and Post‐TEQ were investigated among 474 military personnel with posttraumatic stress...

Considerable evidence supports the utility of evidence‐based protocols in clinical practice in treating a range of psychological symptoms. However, there are significant barriers to their use. We briefly review theoretical models underlying evidence‐based practice and how these relate to use of evidence‐based treatment protocols. We then discuss th...