2013 Continuing Medical

Education Conferences:
Bangkok, Orlando, Dakar

Empirically-Supported Models of
PTSD Etiology and Treatment
Priscilla M. Schulz, LCSW-C
Peace Corps Headquarters
Counseling and Outreach Unit
Washington, DC
 Session Overview
Research-based models
for understanding and treating PTSD
Empirically supported models of post trauma
reactions
o Common psychological responses post trauma
o Normal versus pathological reactions
Empirically supported recommendations for
early post-trauma care
Empirically supported treatments for PTSD
Brief look at Cognitive Processing Therapy
(CPT), a cognitive approach to treating PTSD
 DSM-5:
Acute Stress Disorder &
Post-Trauamtic Stress Disorder

American Psychiatric Association, Jan 2013, From

Planning to Publication: Developing DSM-5
May 2013 DSM-5:
Trauma- and Stressor-Related Disorders

Acute Stress Disorder (ASD): (detailed, next slides)

Adjustment Disorders: An array of stress response syndromes that
occur in response to exposure to traumatic or non-traumatic
events

Posttraumatic Stress Disorder (PTSD) (detailed, next slides)

Reactive Attachment Disorder
 DSM-5 PTSD & ASD Stressor Criterion

A . The person was exposed to one or more of the following event(s):

death or threatened death, actual or threatened serious injury, or
actual or threatened sexual violation, in one ore more of the
following ways:.
1. Experiencing the event(s) him/herself
2. Witnessing, in person, the event(s) as they occurred to others
3. Learning that the event(s) occurred to a close relative or friend; in
such cases, the actual or threatened death must have been violent
or accidental
4. Experiencing repeated or extreme exposure to aversive details of
the event(s): e.g., first responders collecting body parts; police
officers repeatedly exposed to details of child abuse. This does not
apply to exposure to electronic media, TV, movies, or pictures
unless this exposure is work related.
TRAUMA
DSM-5 ASD Symptom Criteria
nightmares
Dissociative amnesia Re-experiencing
flashbacks
reactions detachment reactions
intrusive memories
numbing
repetitive thoughts
reduced awareness of surroundings
emotional reactions
de-realization
physiological reactions
depersonalization

DSM-5 ASD diagnosis requires 9 out of 14 symptoms

Avoidance Arousal
Avoids:
internal & external reminders: sleep disturbances
thoughts, feelings, physical sensations; concentration problems
people, places, objects, conversations, hyper-vigilance exaggerated
situations, & activities startle response
anger & irritability

American Psychiatric Assoc May 2013

May 2013 DSM-5:
PTSD Diagnostic Criteria

A: Stressor Criterion
B: Re-experiencing
C: Avoidance
D: Arousal
E: Negative alterations in cognitions and mood
F: Time Criterion
G: Functional Impairment or Distress
DSM-5 PTSD Symptom Criteria
Re-experiencing
1 symptom
Intrusive memories
Nightmares
Psychological and/or physiological
distress with reminders
Dissociative reactions
Arousal
3 symptoms
Hyper-vigilance Disturbed sleep
Exaggerated startle
Reckless, self-destructive behavior
Irritability, aggression
Difficulty concentrating
American Psychiatric Assoc May 2013
Avoidance
1 symptom
Avoids internal & external reminders:
thoughts, feelings, physical sensations;
people, places, objects, conversations,
situations, & activities
Negative changes in
thoughts and mood
3 symptoms
Feeling detached/estranged
Persistent distorted blame re: trauma
Cannot feel positive emotions
Persistent/exaggerated negative expectations
Cannot recall important trauma details
Pervasive negative emotions
Diminished interest/participation
in significant activities
 The Recovery Model of PTSD
Most individuals will have PTSD symptoms after trauma
exposure
Post-trauma psychopathology is not the presence of
clinically significant distress or functional impairment in
the immediate aftermath of trauma exposure.
Post-trauma psychopathology (PTSD) is the lingering of
clinically significant distress and impairment long after
the trauma and life threat is ended.
it may be best to think about diagnosable PTSD
as a disruption of a normal recovery process.
Resick, Monson, & Chard, CPT for PTSD, 2010, p. 3

Monson, Fredman & Stevens, 2009

 Trajectories of PTSD symptoms among
female rape survivors
Clinically significant
PCL cut point = 45-50
90
PTSD Symptom Checklist (PCL)

80
16.0%; N = 19 High chronic
70
60
Moderate
50 6.7%; N = 8 chronic
40 Moderate
47.9%; N = 57 recovery
30 Marked
20 29.4%; N = 35 recovery
10
0
Natural recovery: ~77%
Month 1 Month 2 Month 3 Month 4 Stalled recovery: ~23%

Steenkamp et al, JTS,2012; N = 119

 Post-assault symptom severity predicts PTSD
30

PTSD
Non-PTSD
25
Percentage meeting PTSD
Symptom Criteria

20

15

10

0
1 2 3 4 5 6 7 8 9 10 11 12

Weeks since sexual assault

Rothbaum, et al., JTS, 1992 N = 95

 Empirically supported/recommended responses
in the immediate aftermath of a trauma
Provide concrete help
o food, warmth, shelter
Soothe:
o reduce states of extreme emotion*
o increase the survivors sense of control
Help the survivor understand and cope with
o overall distress
o repetitive imagery and re-appraisals of the trauma
Be proactive:
o treat specific psychological syndromes such as ASD, MDD,
etc
*Please! Consult with OHS before prescribing medications
US Dept HHS, AHRQ, Comparative Effectiveness Review # 109, April 2013;
VHA, VA/DoD Clinical Practice Guidelines, 2004/2010
Functional model of PTSD,
natural recovery, and first
steps in empirically-
supported PTSD treatment
Symptoms of PTSD, simplified,
fall into two broad categories

Intrusions
Arousal
Negative Irritability
changes in
thought & mood

Core PTS Reactions = Distress Avoidance reactions:

Coping with distress by
escape and avoidance
 Trauma Recovery takes effort. Survivors must experience and
tolerate trauma memories, troubling interpretations, and
accompanying strong emotions.
Trauma memories are indelible, but reduction of trauma-related
distress and impairment define trauma recovery.

Intrusions
Arousal
Irritability
Negative
changes in
thought & mood

Core PTS Reactions

Remembering the trauma allows natural emotions to run their course,
and allows survivors to examine and/or correct troubling
interpretations
Efforts that block trauma memories, and avoid trauma-
related thoughts and feelings impede recovery.

Intrusions Arousal,
irritability
Negative changes
in thoughts/mood

Core PTS Reactions Escape/Avoidance

Effective treatment of PTSD
Step 1: Identify & challenge avoidance

Intrusions
Arousal,
Negative irritability
changes in
thought & mood

Core Symptom Clusters Escape/Avoidance

Effective treatment of PTSD
Step 2: Focus treatment on one or more core PTS
symptom groups
Nightmare re-scripting
PE

Intrusions
Arousal,
Negative irritability
changes in
thought & mood

CT,
CPT-C
EMDR Escape/Avoidance
CPT
Core PTS Symptom Clusters
PTSD basic points
Immediate, intense reactions to traumatic
experiences are expected and normal
Most survivors recover within about 3 months
Severity of reactions post-trauma is associated
with stalled recovery
Avoidance hinders recovery: Avoidance of
memories, reminders, thoughts and feelings
impede post-trauma recovery
Clinical implications in the 1st hours and days
post-trauma. Providers should address
Safety
Physical injuries
Need for emotional support, companionship
Psycho-education about post-trauma reactions and
recovery
o Normalize PTS symptoms
o Educate about the recovery process
o Encourage active processing
o Discourage avoidant coping
o Identify persons in the survivors environment in whom
he/she can confide and begin the recovery process
EMPIRICALLY MODELS of the
ETIOLOGY OF PTSD
Neurobiological, cognitive, and learning
theory models of PTSD
 PTSD is a disorder in which stress-hormone dys-
regulation, and corresponding brain dys-function,
undermines emotion regulation and thinking. Research
suggests this occurs at the time of the trauma, and with
memories long after the trauma occurred.

Memories formed peri-trauma, when stress hormones are at

abnormal levels, are incoherent, fragmented, and lack context.
Memory abnormalities underlie trauma-related distortions.
Avoidance of trauma memories, and trauma reminders,
maintains memory abnormalities, and thinking errors.

Classical conditioning accounts for why certain trauma-related

stimuli later evoke anxiety & a sense of danger.
Operant conditioning, especially the self-reinforcing effect of
avoidance of trauma memories and reminders, maintains the
anxiety response. 23
 NEURO-BIOLOGICAL
MODEL OF PTSD

Physiological abnormalities appear to underlie

problematic stress responses and PTSD.

Bremner et al, 1999b; Milad et al., 2009; Morgan et al, 2000; 2001,
2004; 2006; Rauch et al., 1998, 2000; Shin et al., 2001
Pre Frontal Cortex:
Executive functioning
Amygdala:
Initiates increased vigilance
& defensive preparations in
response too uncertain or
novel stimuli that may be a
threat
Hippocampus:
Weighs relevance of parts
or experience; perceives
context; inhibits fear
conditioning
HPA Axis:
Hypothalamus
Pituitary, and Adrenal Cortex
The Fight-Flight response
Normal Human
Response to Threat Cerebral Cortex
involves a cascade of
DA
central and peripheral
(-) Hippocampus 5HT
nervous system events.
Survival is primary. ((-) NE
(-) Amygdala
Midbrain &
manifests as fight or Brainstem
Glutamate++
flight SNS
Hypothalamus

Glucocorticoids:
CRF
Cortisol
Threat Pituitary
Allopregnanalone
DHEA
Neuropeptide Y
ACTH

Adrenal Cortex
An optimal zone defensive response involves key
neurotransmitters alternating between excitation
and down-regulating the response

Norepinephrine
Fear; flight; learning &
remembering about danger

Serotonin GABA
(5HT) Calming; modulates stress
hormone levels; supports
Rage; fight; self- good cognitive functioning;
defense; aggressive decreases CRF (decreasing
retaliation; attenuation HPA response & NE
of fear release)
How the Amygdala sees threat

As seen by the amygdala

As not seen by the amygdala

Conceptualization courtesy of Ann Rasmusson, MD, Yale University & Boston VA Healthcare System
Top-Down Governance

Milad et al. (2009);

Rauch et al. (2006);
Shin et al. (2005)
vmPreFrontal Cortex
Southwick et al. Enables a nuanced response
(2005); to threat

Hippocampus
context
(-) probability

Amygdala The vmPFC & hippocampus regulate the

(-) (-) threat response initiated by the amygdala.
Together they inhibit fear responding and
fear conditioning
SHUT DOWN is part of the Cerebral Cortex
normal threat response
DA
1. Distress is alleviated 5HT
shortly after threat ends (-) (-) NE
((-)
Hippocampus
2. Responses to non- (-)
Amygdala Midbrain &
threat reminders Brainstem
Glutamate
gradually lose GABA

distressing quality Hypothalamus

Glucocorticoids:
Threat CRF
Cortisol
Pituitary
Allopregnanalone
DHEA
Neuropeptide Y
ACTH

Adrenal Cortex
PTSD vulnerability: Physiological
responses outside optimal levels undermine Cerebral Cortex
emotion regulation & memory formation
DA
Peri-trauma, this
5HT
manifests as dissociative
(-) (-)
reactions. Hippocampus
NE
(-)
Amygdala BDNF Midbrain &
Post-trauma, this (-) Brainstem
Glutamate
manifests as memory
GABA Glucocorticoids:
inaccuracy & problem- Hypothalamus
Cortisol
solving deficits. Allopregnanalone
CRF DHEA
Threat Pituitary Neuropeptide Y
Peri-traumatic dissociation Milad et al. (2009);
increases risk of emotional
Rauch et al. (2006);
overwhelm, increasing risk ACTH
of immediate onset PTSD Southwick et al.
(Ozer et al., 2003) (2005); Shin et al.
Adrenal Cortex
(2005)
Research with US Special Forces found stress hormone dys-
regulation undermined Soldiers and Marines ability to
respond to threat in high stress/live-ammo training
exercises. This resulted in performance deficits including
confusion relaying map coordinates, difficulty operating
weapons, and psychological collapse under mock
interrogations.

Stress hormones dys-regulation seen in Special Forces

survival school training is seen in patients with PTSD.

2003; Morgan III et al, 2000; 2001, 2004; 2006

Abnormal levels of key neurotransmitters
underlie peri-trauma reactions and PTSD
symptoms
Norepinephrine
Fear; Hypervigilance;
arousal; exaggerated
startle; flashbacks &
intrusive memories

Serotonin (5HT) GABA

Violence; aggression; Anxiety;
suicide attempts;
re-experiencing;
impulsivity;
depression;
impulsivity; hyper-
anxiety/panic arousal
Noradrenergic and HPA Axis dys-regulation appear to
underlie compromised thinking during a trauma.

Noradrenergic and HPA axis alterations

are associated with irrationality and labile emotions.

Birmes, et al., Morgan III et al, 2000; 2001, 2004; 2006

The Cognitive Model of PTSD
MEMORIES & CONCLUSIONS MADE
UNDER INTENSE EMOTIONAL
AROUSAL
Ignore context
Are automatic impressions,
NOT thoughtful or fair assessment of the facts

Are like snapshots of the experience

Tend to support prior-held beliefs disregarding

contradictory evidence
Favor some details over others
Tend to view the future in
extreme & catastrophic
terms
Dunmore et al., 2001Ehlers & Clark, 2000; Hackmann
et al., 2004; Halligan et al., 2003; Speckens et al., 2007
Disorganized trauma memories are
SNAPSHOTS OF EXPERIENCE

Farras Abdelnour, artist

Three kinds of mental activity peri-trauma are
linked with disorganized trauma memory
formation

1. Lack of self-referent processing

2. Dissociation
3. Data-driven processing

Birmes et al., 2003; Dunmore et al., 2001; Halligan, Michael, Clark, & Ehlers (2003)
1. LACKING SELF-REFERENCE
persons dont recognize themselves during the trauma
2. DISSOCIATIVE PROCESSING:
perspective, sense of time & space are distorted
3. DATA-DRIVEN,SENORY FOCUSED:
persons are overwhelmed by sensory experiences
At the mercy of an emotional mind, survivors with PTSD share
Common Interpretative Biases
The world is unpredictably dangerous
People are untrustworthy
No place is safe
Threats could appear at any moment
Its my fault (Im bad)
My training tells me outcome reflects preparations. The outcome was bad;
the mission my responsibility. So the only conclusion left is: its my fault
I promised Id bring everyone back alive
I should have/could have done something
I believe good things happen to good people
I am unable to cope (Im incompetent)
PTSD symptoms are a sign of weakness
Other people would get over it

Dunmore et al., 2001; Ehlers & Clark (2000)

 THE LEARNING MODEL OF PTSD:
Fear of non-threat stimuli is learned automatically.

Amygdala non-threatening stimuli

acquire capacity to trigger the
full defensive response.

Associative LTP

Unconditioned
Stimulus Conditioned
Stimulus
Post-trauma Fear Structure
Representation of The meaning associated
Physiological
feared, trauma-related with stimuli &
fear response
stimuli responses
People walking Racing heart Someones coming to hurt
behind you Sweating me!
Pictures of bears or Agitation I cant protect myself.
Alaskan wilderness Panic Im in danger!
The smell of mens Escape No place is safe!
aftershave behaviors

Craske et al., BRT, 2008; Foa et al., 2007, PE for PTSD; Foa & Kozak, Psychological
Bulletin,1986; Foa et al., 2006; Foa & Rothbaum, 1998; Lang, 1979; Lang et al., 1998
 Operant conditioning maintains the link between
trauma reminders and a sense of dangerousness

Do something Experience a consequence Do it more, or less

Avoid Not thinking about
Avoid memories
trauma what happened makes
memories me feel in control. more & more

Try to deal Strong negative Think about the

with trauma feelings; trauma less &
memories Feel unable to cope less
When memories start-
Distract self
up, I play loud music, & Distract from
from trauma
that makes the memories memories more
memories
go away.
Feel intensely upset: Think about the
Face trauma
memories
It ruined a good trauma less &
day! less
 Vicious Cycle:
Distress Avoidance Distress Avoidance ..

Trauma memories
cause distress

Distract self,
Avoid anything
prevent
that triggers
opportunities to
memories
remember

Trauma memories
intrude and cause
distress
Conditioned fear remains intact until new associations
rival the ones learned during the trauma

Amygdala
New learning prevents
activation of threat
response

Craske, M. G. (2010); Craske, M. G., et al. (2008); Myers & Davis (2007
Clinical implications based on PTSD models:
1st weeks post-trauma
1. Assessment:
a. Primary Care PTSD Screen (PC-PTSD)
b. Descriptions of symptom change since the incident:
Im not as upset as I was the first week versus
If the nightmares dont stop Im going to go crazy!
c. Survivors behavior coping with the trauma:
Avoiding people? avoiding eye contact?
increased use of benzos or alcohol? versus
Calling home. Talking with OVA, COU. Accepting
companionship. Seems calmer/ more focused daily
Primary Care PTSD Screen
Have had nightmares about it or thought about it when you did
not want to? YES / NO

Tried hard not to think about it or went out of your way to avoid
situations that reminded you of it? YES / NO

Were constantly on guard, watchful, or easily startled? YES / NO

Felt numb or detached from others, activities, or your

surroundings? YES / NO
Clinical implications based on PTSD models:
1st weeks post-trauma
2. Psycho-education: Remind the survivor about
o Post-traumatic stress symptoms
o The importance of active recovery
o The problems of avoidance
3. Look for signs of maladaptive coping
o Social isolation
o Negative changes in mood and thoughts
o Increased substance use
4. Psycho-education: If appropriate, start sharing info
about empirically supported PTSD treatments
o Cognitive Processing Therapy (CPT)
o Prolonged Exposure (PE)
 The spectrum of post-trauma reactions reflects pre-
trauma risk & resilience factors, trauma severity, etc
 EMPIRICALLY MODELS of PTSD
RISK and RESILIENCE
Environmental, developmental, personality and genetic
factors that affect variability in the post-trauma response
 GxE model
Individual social
Community
environment
environment (e.g.,
(upbringing; learned
high crime rate, post-
coping skills;
conflict country, etc)
financial security, etc)

Genetic variants:
Kinds of trauma & FKBP5
age of exposure SLC6A4
PTSD & RGS2
related
phenoptypes:

Koenen et al, JTS, 2009

Genetics and PTSD:
The effects of trauma exposure may differ according to
an individuals genetic disposition

PTSD

Trauma FKBP5 rs 1360780 AG

Good post-
trauma
recovery
FKBP5 rs 1360780 GG
Epigentics and PTSD:
Early trauma may alter the function of a gene involved in
the human stress response resulting in problematic stress
responses when exposed to later traumatic events.
CHLDHOOD TRAUMA

STRESS SYSTEM GENES

POST-TRAUMA RESPONSE
Severity, FKBP5 PTSD+
frequency NR3C1 No PTSD
childhood
abuse SLC6A4 etc Subsyndromal
PTSD
 1. Gene-Environment Interaction (GxE): The effects of adult trauma
exposure are moderated by genotype, AND by levels of childhood abuse that
appears to affect gene expression through epigentic changes.
90%
80%
70%
No sexual or physical
lifetime PTSD (CAPS)

60% abuse
Percentage with

50% Sexual or physical abuse

40%
30% Sexual and physical abuse
20%
10%
0%
FKBP5 rs 1360780 GG FKBP5 rs 1360780 AG/AA
(protective genotype) (risk alleles)

Klengel et al., Nat Neuroscience, 2013; N = 519

2. Cognitive strength:
Neurobiological soft signs are associated with higher rates of PTSD

Gurvits, et al. Arch Gen Psychiatry, 2000

3. Trauma characteristics, peri-trauma functioning,
post-trauma sequelae predict recovery:
Interpersonal violence

Peri-traumatic dissociation
Perceived life threat
Prior emotional problems
Family of origin psychopathology
Prior trauma
Perceived [lack of] support post-trauma

Ozer, Best, Lipsey & Weiss (2003)

 4. Personality: Internalizing and Externalizing personality
characteristics underlie variability of PTSD presentations as well as
patterns of co-morbidity seen in PTSD.

Panic Disorder .70 The look of PTSD

.58 Fear reflects and is a
OCD product of strengths
.67
& vulnerabilities of
PTSD .93
each individual who
Major Depression .60 Anxious experiences trauma.
Misery .20
.37
ETOH Dependence
.26 .67
Drug Dependence .54
.53 Externalizing
Antisocial PD

Miller et al., JTS, 2008; N = 1,325

 Internalizing characteristics (e.g.,
shy, unassertive, self-deprecating)
put females only at risk for assaultive
violence.

1. undermines motivation and skills to avoid or to get out

of physically assaultive situations

2. impedes contextual awareness and mental focus

needed to detect potentially violent situations

Acierno et al (1999) J of Anx Disorders; Haller & Chassin (2012) JTS

5. Childhood adversity: Childhood characteristics
and environmental stressors in childhood increase risk
for PTSD in adulthood.

Low IQ
Difficult temperament, antisocial behaviors,
unpopular among peers
Low family SES
Multiple changes in residence before age 11
Changes in a parent figure (e.g., divorce,
death, etc.)
Mothers identified with internalizing personality
traits
Koenen, Moffitt, Poulton, Martin & Caspi (2007).
 Clinical implications of risk & resilience
information about PTSD:
1. Consider the Volunteers mental health history:
a. Volunteers with prior psychiatric difficulties may experience
similar problems after a traumatic event
2. Screen for PTS reactions: Severity may suggest risk
3. Assess for PTSD at 1-month post trauma
4. Follow-up with Volunteers with childhood adversity histories
who may hide or minimize current distress
5. Help Volunteers use skills learned from other difficulties to
address emotional difficulties in the aftermath of a trauma:
a. How did the Volunteer calm & support herself after PST?
b. How did she garner support when feeling lonely or scared?
RESEARCH-SUPPORTED
TREATMENTS of PTSD

Cognitive Processing Therapy

Prolonged Exposure
 Evidence-based PTSD treatment recommendations

GUIDELINE AUTHORITY A-LEVEL TREATMENTS

US Departments of VHA & DoD: CT, ET, SIT, EMDR
2004/10
ISTSS: 2000/09 ET, CPT, CT, SIT
Amer. Psychiatric Association 2004 Trauma-Focused CBT (TF-CBT)

Institute of Medicine 2007 ET (includes CPT)

UK-Natl Institute for Clinical TF-CBT, EMDR
Excellence 2005
Australia National Health & Medical TF-CBT, EMDR w/in-vivo EX
Research Council 2007

Forbes et al., (2010). JTS.

 AHQR Strength of Evidence (SOE) Findings
TREATMENT OUTCOMES SOE
Cognitive Processing Therapy PTSD Symptoms Moderate
PTSD Diagnosis resolved Moderate
Symptoms of depression Moderate
Cognitive Therapy PTSD Symptoms Moderate
PTSD Diagnosis resolved Moderate
Symptoms of depression Moderate
CBT-Exposure Therapies PTSD Symptoms High
PTSD Diagnosis resolved Moderate
Symptoms of depression High
CBT-Mixed* PTSD Symptoms Moderate
PTSD Diagnosis resolved Moderate
Symptoms of depression Moderate
US Dept HHS, AHRQ, Comparative Effectiveness Review # 92, April 2013
Cognitive Processing Therapy (CPT)
CPT is a manualized 12-session cognitive therapy for PTSD with a
primary focus on challenging and modifying maladaptive beliefs
related to the trauma. It includes a written exposure component.
In CPT asks survivors to write about the impact (thoughts) and
content (story details in order of occurrence) of a traumatic event.
CPT aids recovery by teaching survivors ways to examine the
trauma, and change initial interpretations to better fit the facts. At
the same time CPT encourages patients to feel and process
natural emotions associated with the experience.
CPT leaves survivors with new skills and tools to cope with future
adversities.
Trauma-associated problems such as depression, guilt and anger
are also addressed in CPT.
The mind is not a camera
(Dror& Fraser-Mackenzie, 2008)

Values Hopes
Expectations
Biases
State-of-mind

Motivation
Meaning stems from an interaction

Trauma

Schema, or Core Beliefs

 E.g., Acquaintance Rape
Good things happen Friends dont Maybe its a
to good people hurt friends misunderstanding, not a
When you wear the
rape
right shoes

Im in I could have
control of prevented this
my life

Think happy
thoughts
Beliefs
Trauma
I mustve done
something
and wrong

I can trust the PC people

to not take advantage of Bad things happen I mustve wanted
others vulnerabilities when good people what happened; if Im
do nothing hurt its my fault
Some conclusions that may not be accurate
and impede post-trauma recovery
Stem from, and are biased towards, prior beliefs:
o Such bias makes it difficult to consider or to notice trauma
details that dont fit expectations, or that dont fit ones scheme of
why things happen;
And such conclusions...
Remain unexamined because of PTSD avoidance.
As a result
Initial attributions of fault:
o Remain frozen-in-time;
o Sometimes stand-in for the actual, factual trauma account;
o Interfere with recovery because they exacerbate distress, adding
reasons to avoid trauma memories, thoughts and feelings.
Other conclusions are so focused on preventing
future harm survivors make decisions that are
extreme
I cant get close
I can get close to anyone
Betrayal to others
Danger

Trauma
Beliefs

The world is safe
The world is
Powerlessness completely unsafe
CPT identifies beliefsprior beliefs, trauma
conclusions, and how these ideas affect wellbeing

Traumatic loss examples:

I shouldve been able to save him.
Admitting to feelings is a sign of weakness.
Its my fault they died; I didnt act quickly enough.
Sexual violence examples:
Its my fault; I shouldve fought back.
Im bad because I never told anybody about the abuse.
It happened because I make bad choices.
CPT teaches thought-monitoring and the connection
between thoughts, emotions and behaviors
 CPT patients practice thought monitoring and
observing the impact beliefs have on wellbeing

On Facebook I saw No one will ever want me! Sad,

an old boyfriend ashamed,
announce hes Im damaged goods! disgusted
getting married

Maybe not entirely; I cant predict the future

Some of my friends know whats happened,
male and female, and they value our
friendship. I suppose a romantic relationship
could start like that.
CPT asks individuals to review the
trauma experience in detail
Connects survivors to their natural
emotions whose expression may have
been truncated
Reveals facts that help determine the
accuracy or biases of initial trauma
conclusions
 then, CPT teaches
critical thinking

opens doors previously closed to inquiry

examines ideas for accuracy or biases
helps re-construct conclusions to better
account for the facts
improves management of strong emotions
through better pre-frontal cortex
involvement in emotionally powerful
memories, images and ideas
 If only I had done X, I could have stopped
the ______ [trauma] from happening.
Had no options
Were there options, other
than X at the time?
Statement is not true.
Was X an option at
may reflect wishful thinking
the time? If patient had considered
options, go thru these choices,
YES NO & consider possible outcomes. Alternative thought:
not just fantasy outcomes I couldnt have stopped X

What are reasons you

did not choose X?
Could the outcome been
worse if youd done X?
consider this in context

How does this

feel? Different?
CPT helps survivors consider how to make sense of the
trauma in a way thats factual, and not extreme but balanced.
Bad things Betrayal
happen to good Good people can
people do bad things

Trauma Danger
RECOVERY

I have power over A different action Powerlessness

many, but not all might have had a
things worse outcome
 CLINICAL EFFECTIVENESS
OF CPT & PE
Empirical basis for using CPT and PE to treat PTSD
with Peace Corps Volunteers/survivors of
traumatic experiences
CAPS SEVERITY PRE- AND POST-TREATMENT
(INTENT-TO-TREAT)

Pre Post

90
80
70
CAPS SEVERITY

60
50
40
30
20
10
0
Resick et al. Chard (2005) Monson et al. Resick et al. Forbes et al. Suris et al.
(2002) (2006) (2008; CPT) (in press) (under review)
 BDI SEVERITY PRE- AND POST-TREATMENT
(INTENT-TO-TREAT)
Pre
30
Post
25
20
BDI Severity

15
10
5
0
Resick et al Chard Monson et al Resick et al Forbes et al
(2002) (2005) (2006) (2008) (in press)
CPT
RANDOM REGRESSION
OF PDS

82
 Long-term impact of CPT and PE:
PTSD symptom improvement is maintained over time.
PTSD Symptom Severity (CAPS)

Therapist ratings Resick et al. 2011, N = 171

 Long-term impact of CPT and PE:
PTSD symptom improvement is maintained over time.
PTSD Symptom Scale (PSS)

Patient ratings Resick et al., 2011, N = 171

 Guilt Cognitions Over Time
Trauma-Related Guilt Inventory

2.5
CPT
PE
2

1.5

0.5

0
PreTx PostTx 3 MO 9 MO 5+ Yrs
Resick et al.,2002; 2011
86
 The end.
Thank you!