Posttraumatic stress disorder (PTSD) is a severe and often chronic anxiety disorder that can develop following exposure to an event involving actual or perceived threat to the life or physical integrity of oneself or another person. Epidemiological studies such as the National Comorbidity Survey1 estimate that more than half the population of the United States has experienced one or more traumatic events and that 8% of the population has met criteria for lifetime PTSD. Thus, trauma and PTSD are significant mental health problems.
In this article, we provide a summary of research on the efficacy of treatments for PTSD and suggest directions for future work. Although numerous psychological therapies have been suggested and used in patients with PTSD, most efficacy research using gold standard randomized controlled treatment methodology2 has focused on various cognitive-behavioral therapy (CBT) programs. Accordingly, our review will also focus on CBT.
Description of CBT procedures
CBT is a broad term covering a number of interventions designed to challenge and modify erroneous cognitions, reduce the intensity and frequency of distressing negative emotional reactions via exposure to safe but feared situations and objects, and promote effective coping. Two erroneous cognitions commonly found in patients with PTSD are that the world is entirely dangerous and that the person with PTSD is incompetent.3 CBT is a short-term approach, usually involving 9 to 12 individual sessions lasting 60 to 90 minutes, and administered once or twice weekly. Patients are usually assigned homework to practice the specific interventions between sessions.
The most frequently used interventions for PTSD are exposure therapy, stress inoculation training (SIT), and cognitive restructuring. These interventions may be administered as stand-alone treatments or combined into a more comprehensive treatment package. A fourth treatment for PTSD, eye movement desensitization and reprocessing (EMDR),4 incorporates elements of exposure and cognitive restructuring with therapist-directed rapid eye movements or other laterally alternating activities.
Exposure therapy is a set of treatment procedures designed to help individuals confront feared but safe thoughts, situations, objects, people, places, or activities that elicit anxiety or are otherwise avoided because they are perceived as dangerous by patients with PTSD. Exposure to feared but safe situations is a major component of treatment for other anxiety disorders such as phobias, social anxiety disorder, obsessive-compulsive disorder, and panic disorder/ agoraphobia.5
For PTSD, exposure therapy typically involves imaginal exposure to the trauma memory in which patients are instructed to close their eyes and recall the traumatic event by imagining that it is happening right now while simultaneously describing out loud what is being remembered. Patients are encouraged to provide a detailed description of the memory, including all important sights, sounds, smells, tastes, and physical sensations, along with thoughts and emotional reactions that occurred during the trauma. These trauma narratives are repeated several times in the therapy session over the course of 20 to 45 minutes and recorded for the patient to listen to as daily homework.
In addition to imaginal exposure, patients practice in vivo exposure to real life stimuli that trigger trauma-related memories and distress.6 This is accomplished through identifying the people, places, situations, and activities that trigger anxiety and avoidance because of the trauma; evaluating each one for safety and for relevance to the patient's normal functioning; then repeatedly confronting selected situations for prolonged periods until there is a significant reduction in the patient's anxiety. To facilitate in vivo exposure, a hierarchy is constructed that begins with targets of moderate difficulty and then moves gradually to more challenging targets as the patient succeeds with the lower items.
The goal of imaginal and in vivo exposure is to help patients process the traumatic memories and correct erroneous cognitions about the world and the self.