CBT for PTSD: Summary

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.

Highlights

  • Prolonged exposure therapy (PE) is a specific protocol for PTSD that has been found effective across trauma populations.
  • PTSD can be conceptualized as a disorder of extinction.
  • PE aims to decrease distress associated with the trauma reminders and change trauma-related cognitions.

 

Transcript

Welcome to this video, Take-Home Messages.
Cognitive behavioral treatment, or CBT, for PTSD involves helping the patient confront the reminders of the trauma in a therapeutic manner so that the stress decreases. Exposure therapy has more evidence of its efficacy for PTSD than any other intervention. PE, or prolonged exposure therapy, is a specific protocol for exposure therapy for PTSD that has been found effective across trauma populations and in different cultures.

The DSM-5 diagnostic criteria for PTSD includes an outside event, the trauma. And the subcategories of DSM-5 diagnostic criteria for PTSD include symptoms of intrusion, avoidance, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. The DSM symptoms of PTSD are part of the normal response to trauma.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Fear and anxiety are a normal response to trauma. And for most people, this fear will extinguish over time. But for some, usually due to avoidance, the fear does not extinguish.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

PTSD can be conceptualized as a disorder of extinction. Fear structures contain information about the feared stimuli, the fear responses, and the meaning.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

PE involves promoting emotional engagement with the trauma memory. We want all exposures to be therapeutic exposures. We want something to change. We aim to decrease distress associated with the trauma reminders and change trauma-related cognitions.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.
Minnen, A. and Foa, E., 2006. The effect of imaginal exposure length on outcome of treatment for PTSD. Journal of Traumatic Stress, 19(4), pp.427-438.

Many therapists are reluctant to use PE due to myths about exposure therapy. Myths about exposure therapy include that patients can’t handle it, patients are too complicated for PE, exposure therapy is cruel and that exposure therapy takes away the patient’s autonomy. These myths are not true and research and therapists’ experience dispels them.

References

Astin, M. C., & Rothbaum, B. O. (2000). Exposure therapy for the treatment of posttraumatic stress disorder (9,4). National Center for Posttraumatic Stress Disorder.

We recommend measurement-based therapy. Measurement-based therapy for PTSD includes clinician-rated scales such as the CAPS-5 and self-report scales such as the PCL-5 and the PHQ-9. These should be administered at a minimum pre- and post-treatment, but best practices include administering measures about every other session to monitor progress.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

There’s something inherently healing and liberating about saying aloud the worst, most shameful moments of one’s life and having another person witness and accept it for what it is. We encourage you to give your patients this gift. As any therapist who has listened to a painful and horrifying experience can attest, helping a patient to emotionally process traumatic events can be challenging and emotionally difficult even when we’re rewarded by seeing the benefits of effective treatment. In order to conduct PE, therapists sometimes need to develop or increase their own tolerance for patient distress.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

Session 1 includes presenting the patient with an overview of the treatment program and a general rationale for PE, collecting information about the trauma, and ends with the introduction of breathing retraining.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

Imaginal exposure to the trauma memory and processing begins in session 3 and continues each session for the remainder of therapy. The hierarchy for in vivo exposure is constructed in session 2, and in vivo exposure homework is assigned in session 2 and continues each session for the remainder of therapy.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

Patients should remain in the exposure long enough for distress to decrease. Patients should be encouraged to use as much detail as possible.
Therapists should praise patients for this difficult but worthwhile work.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

Minnen, A. and Foa, E., 2006. The effect of imaginal exposure length on outcome of treatment for PTSD. Journal of Traumatic Stress, 19(4), pp.427-438.

And we’ll talk about later virtual reality exposure therapy as a new medium of exposure therapy that has been shown to be effective.

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