Post Traumatic Stress Disorder: Cognitive, Cognitive–Behavioral and Behavioral Therapies

Cognitive, Cognitive–Behavioral and Behavioral Therapies

Despite theoretical differences, most schools of psychotherapy recognize that cognitively oriented approaches to the treatment of anxiety must include an element of exposure. Because PTSD involves aberrant and voluntary programs for the avoidance of danger that are conditioned by real experience, correction of these “fear structures” requires exposure to ensure habitua-tion. Although a range of possible PTSD interventions has re-cently been reviewed (Foa et al., 2000) including group therapy, cognitive–behavioral therapy, eye movement desensitization and reprocessing, and psychodynamic therapy, the preponderance of current evidence suggests that the primary effective compo-nent of PTSD treatment is prolonged exposure (Rothbaum et al., 2000). Prolonged exposure depends on the fact that anxiety will be extinguished in the absence of real threat, given a sufficient duration of exposure in vivo or in imagination to traumatic stim-uli. In PTSD, the patient retells the traumatic experience as if it were happening again, until doing so becomes a pedestrian ex-ercise and anxiety decreases. Between sessions, patients perform exposure homework, including listening to tapes of the flooding sessions and limited exposure in vivo. A review of 12 studies sug-gests that prolonged exposure is a component of the most well-controlled study designs and is associated with positive results (Rothbaum et al., 2000). However, not every patient may be a candidate for exposure. Due to the high anxiety and temporar-ily increased symptoms associated with prolonged exposure, there are patients who will be reluctant to confront traumatic re-minders. Patients in whom guilt or anger are primary emotional responses to the traumatic event (as opposed to anxiety) may not profit from prolonged exposure. More empirical research is needed to evaluate how this efficacious treatment can be most effectively implemented in nonacademic settings. In addition, additional research is needed to identify methods to increase pa-tient tolerability of the treatment.

Anxiety management techniques are designed to reduce anxiety by providing patients with better skills for controlling worry and fear. Among such techniques are muscle relaxation, thought stopping, control of breathing and diaphragmatic breath-ing, communication skills, guided self-dialogue and stress in-oculation training (SIT). Although these interventions have less empirical evidence regarding treatment efficacy for PTSD, gen-erally the results are positive and further controlled evaluation across trauma population samples is needed.

Further, cognitive approaches to the treatment of PTSD have also gained empirical support. A cognitive approach to treatment includes training patients in challenging prob-lematic cognitions such as self-blame. In a recent comparison of cognitive therapy to imaginal exposure in the treatment of chronic PTSD, both treatments were associated with positive improvements at post treatment and follow-up, with no differ-ences in outcome between treatments. However, patients who received imaginal exposure were more likely to experience an increase in PTSD symptoms during the treatment course, and those who did were more likely to miss treatment sessions, rate the therapy as less credible and be rated as less motivated by the therapist.

In contrast to the treatment-efficacy literature for adults with PTSD, the child-focused PTSD literature is limited to open trials and case reports. Treatment practices for childhood PTSD have recently been surveyed (Cohen et al., 2001). Clearly, adult treatment approaches need to be empirically evaluated for use in children with PTSD. As no single treatment for PTSD has been shown to be curative, patient characteristics, characteriza-tion of the nature and range of stress responses of trauma vic-tims, partial response, treatment combinations, sequencing of treatment approaches and further well-controlled investigations of current approaches are all important empirical topics to be addressed.