What is PTSD?
Post-traumatic stress disorder (PTSD) is a debilitating mental condition that develops after exposure to extreme stress or a traumatic event. While the majority of people will resolve the short-term distress such an event causes, individuals with PTSD continue to be affected for much longer.
PTSD is characterized by a variety of cognitive, behavioral, and physiological symptoms related to re-experiencing the event, avoiding reminders of it, and physiological hyperarousal, such as insomnia or irritability. It is estimated that PTSD affects up to 10% of people at some stage of their lives; however, prevalence rates in people who have suffered a traumatic event may be close to 100%.
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What is cognitive-behavioral therapy?
Cognitive-behavioral therapy (CBT) has been used for the treatment of PTSD for many years. CBT aims to improve a person’s functioning by changing their patterns of behaviors, thoughts, and feelings.
CBT is based on the premise that improvements in one domain can lead to benefits in the others. For example, changing detrimental thoughts to be more helpful can help to improve a person’s mood and lead to healthier behaviors. To this end, CBT is usually administered over 12-16 sessions to an individual or a group.
CBT for PTSD
Some techniques employed by therapists when administering CBT include:
- Modifying cognitive distortions (e.g., overgeneralizing bad situations or having negative expectations) and supporting the development of more balanced and beneficial ways of thinking.
- Exposing patients to reminders of the trauma, in a controlled manner, to enable them to confront, rather than avoid, their distress.
- Educating the patient about common reactions to trauma, planning for potential crises, and teaching them to manage stress and promote relaxation
These methods are intended to help the patient with PTSD gain a more objective understanding of their traumatic experience, return their sense of control and self-confidence, and improve their ability to cope and reduce avoidance behaviors.
Cognitive Behavioral Therapy as Treatment for PTSD
Benefits of CBT
The beneficial effects of CBT are generally attributed to modifying the detrimental cognitive distortions experienced by sufferers of PTSD. The response to CBT has also been associated with physiological, functional neuroimaging, and electroencephalographic changes, including:
- A greater decrease in heart rate reactivity and an improvement in blood pressure response on standing in PTSD patients after CBT
- Non-responders to CBT have shown significantly poorer verbal memory than responders and were also found to have impaired narrative encoding
- Motor vehicle accident survivors who received CBT had a greater reduction of right anterior activation of spontaneous electroencephalographic activity compared with controls. Across both groups, a reduction in PTSD symptoms was positively correlated with a decrease in right anterior activation to the trauma stimulus
- CBT response has been associated with functional magnetic resonance imaging (MRI) responses of the brain, with a poor response correlating with the greater bilateral amygdala and ventral anterior cingulate activation in response to masked fearful faces. This enhanced amygdala response may indicate a reduced ability to manage the anxiety reactions that CBT triggers, thus limiting response to therapy.
How does CBT Compare with other therapies?
Eye movement desensitization and reprocessing (EMDR) is another widely used therapy for PTSD with similar efficacy to CBT. This approach was originally developed by Dr. Francine Shapiro, who noticed that disturbing thoughts were alleviated by certain eye movements.
EMDR is based on the idea that negative thoughts, feelings, and behaviors are caused by inadequately processed memories. The technique requires the patient to focus on distressing images while engaging in additional bilateral sensory input, typically side-to-side eye movements.
Although generally found to be equally efficacious as CBT, controversy exists over whether the benefits of EMDR are due to voluntary eye movements that are altering the excitatory/inhibitory elements in the brain, or its similar properties to CBT, such as desensitization and exposure.
CBT has been found to be a safe and effective therapy for both acute and chronic PTSD after a variety of traumatic experiences, in adults and children, and across many cultures. CBT is associated with better remission rates as compared to other supportive therapies such as supportive psychotherapy, problem-solving therapy, present-centered therapy, psychodynamic therapy, acupuncture, hypnotherapy, and structured writing therapy.
However, studies have shown that the number of PTSD patients who do not respond to CBT can be as high as 50%. Dropouts are common, and many patients do not manage to attain remission. This may be due to a number of factors, such as other comorbid conditions like depression, and/or the nature of the study population (e.g., less education, lower level of functioning).
Over the long term, CBT improves overall symptom severity in PTSD patients as compared to non-CBT, but does not necessarily alter the overall diagnostic status of patients. Patients who receive CBT report less intense PTSD symptoms than patients who receive supportive counseling.
There is some evidence to suggest that CBT may also have preventative benefits; however, study findings are mixed, and more research is needed in this area. A review and meta-analysis recommended no use of psychological interventions following traumatic events for the prevention of PTSD. This study also indicated that interventions may have an adverse effect on some people.
There does not appear to be a benefit in combining CBT with pharmacotherapy. The Australian Clinical Practice Guidelines for PTSD recommends that trauma-focused psychological therapy in the form of CBT or EMDR should be used over medication.
CBT is an effective therapy for acute and chronic PTSD, in children and adults, across many cultures, following a variety of traumatic events, with both short- and long-term benefits attributed to both psychological and neurophysiological changes.
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