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                                                                            Neuropsychiatric Disease and Treatment                                                                                                                                                                                                                                                                                                                                                                                                                               Dovepress
                                                                                                                                                                                                                                                                                                                                                                                                                                                                   open access to scientific and medical research
                                                                                        Open Access Full Text Article                                                                                                                                                                                                                                                                                                                                                                                                                                             Review
                                                                            Cognitive behavioral therapy for the treatment  
                                                                            of post-traumatic stress disorder: a review
                                                                            Nilamadhab Kar                                                                                                                                                  Background: Post-traumatic stress disorder (PTSD) is a psychiatric sequel to a stressful 
                                                                            Department of Psychiatry,                                                                                                                                       event or situation of an exceptionally threatening or catastrophic nature. Cognitive behavioral 
                                                                            wolverhampton City Primary                                                                                                                                      therapy (CBT) has been used in the management of PTSD for many years. This paper reviews 
                                                                            Care Trust, wolverhampton, UK                                                                                                                                   the effectiveness of CBT for the treatment of PTSD following various types of trauma, its 
                                                                                                                                                                                                                                            potential to prevent PTSD, methods used in CBT, and reflects on the mechanisms of action of 
                                                                                                                                                                                                                                            CBT in PTSD.
                                                                                                                                                                                                                                            Methods: Electronic databases, including PubMed, were searched for articles on CBT and 
                                                                                                                                                                                                                                            PTSD. Manual searches were conducted for cross-references in the relevant journal sites.
                                                                                                                                                                                                                                            Results: The current literature reveals robust evidence that CBT is a safe and effective inter-
                                          For personal use only.                                                                                                                                                                            vention for both acute and chronic PTSD following a range of traumatic experiences in adults, 
                                                                                                                                                                                                                                            children, and adolescents. However, nonresponse to CBT by PTSD can be as high as 50%, 
                                                                                                                                                                                                                                            contributed to by various factors, including comorbidity and the nature of the study  population. 
                                                                                                                                                                                                                                            CBT has been validated and used across many cultures, and has been used successfully by 
                                                                                                                                                                                                                                            community therapists following brief training in individual and group settings. There has been 
                                                                                                                                                                                                                                            effective use of Internet-based CBT in PTSD. CBT has been found to have a preventive role in 
                                                                                                                                                                                                                                            some studies, but evidence for definitive recommendations is inadequate. The effect of CBT has 
                                                                                                                                                                                                                                            been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD. 
                                                                                                                                                                                                                                            Many studies also report physiological, functional neuroimaging, and electroencephalographic 
                                                                                                                                                                                                                                            changes correlating with response to CBT.
                                                                                                                                                                                                                                            Conclusion: There is scope for further research on implementation of CBT following major 
                                                                                                                                                                                                                                            disasters, its preventive potential following various traumas, and the neuropsychological 
                                  Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 54.191.40.80 on 03-Jul-2017                                                                                          mechanisms of action.
                                                                                                                                                                                                                                            Keywords: post-traumatic stress disorder, cognitive behavioral therapy, prevention, treatment, 
                                                                                                                                                                                                                                            mechanisms of action, trauma
                                                                                                                                                                                                                                            Introduction
                                                                                                                                                                                                                                            Post-traumatic stress disorder (PTSD) is a debilitating mental health condition 
                                                                                                                                                                                                                                             frequently associated with psychiatric comorbidity and diminished quality of life, 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     1
                                                                                                                                                                                                                                            and typically follows a chronic, often lifelong, course.  Given the ubiquitous nature 
                                                                                                                                                                                                                                            of threatening or catastrophic trauma, PTSD is becoming more and more common. 
                                                                            Correspondence: Nilamadhab Kar                                                                                                                                  It may affect 10% of women and 5% of men at some stage.2 Depending upon the 
                                                                            Corner House Resource Centre,                                                                                                                                   nature and degree of the traumatic event, the prevalence rates of PTSD in victims 
                                                                            300 Dunstall Road, wolverhampton, 
                                                                            wv6 0NZ, UK                                                                                                                                                                                                                                                                                                                         3
                                                                                                                                                                                                                                            have been reported to approach 100%.  The PTSD syndrome is a conglomeration of 
                                                                            Tel +44 190 255 3798                                                                                                                                            various cognitive, behavioral, and physiological disturbances characterized by three 
                                                                            Fax +44 190 255 3383 
                                                                            email nmadhab@yahoo.com                                                                                                                                         symptom clusters, ie, intrusion, avoidance, and arousal.
                                                                            submit your manuscript | www.dovepress.com                                                                                                                      Neuropsychiatric Disease and Treatment 2011:7 167–181                                                                                                                                                                                                                                                                                                167
                                                                            Dovepress                                                                                                                                                       © 2011 Kar, publisher and licensee Dove Medical Press Ltd. This is an Open Access article  
                                                                            DOI: 10.2147/NDT.S10389                                                                                                                                         which permits unrestricted noncommercial use, provided the original work is properly cited.
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                                                                         Since the introduction of PTSD into the diagnostic                                                                                                                                                                                                          victims of the 2005 London bombings was well maintained 
                                                                                                                                                                                                4                                                                                                                                                                                                                                                                 43
                                                          classificatory systems in 1980,  considerable research has                                                                                                                                                                                                                 at an average of one year later.  Patients with PTSD second-
                                                          been done on the efficacy of cognitive behavioral therapy                                                                                                                                                                                                                  ary to the bomb explosion in Omagh received an average of 
                                                                                                                                                             5
                                                          (CBT) in its treatment.  Currently, trauma-focused CBT is                                                                                                                                                                                                                  eight treatment sessions by staff with modest prior training 
                                                          recommended for PTSD by various treatment guidelines                                                                                                                                                                                                                       in CBT for PTSD. However, the degree of improvement was 
                                                                                                                                                                                     6–10
                                                          and expert consensus panels.                                                                                                            The purpose of this review                                                                                                         comparable with that in reported research trials, in spite of 
                                                          is to evaluate the studies of CBT for PTSD following vari-                                                                                                                                                                                                                 the fact that almost half of the patients (53%) had psychiatric 
                                                                                                                                                                                                                                                                                                                                                                                          44
                                                          ous types of trauma, and those related to physical disorders                                                                                                                                                                                                               comorbidity.
                                                          in adults, children, and adolescents. It is also intended to 
                                                          review the long-term outcome and preventive role of CBT                                                                                                                                                                                                                    war trauma
                                                          in PTSD and various modes of delivery of CBT in practice,                                                                                                                                                                                                                  The traumas of war have long been associated with PTSD. 
                                                          and the current understanding of its mechanism of action is                                                                                                                                                                                                                In addition, soldiers exposed to combat remain at high risk 
                                                                                                                                                                                                                                                                                                                                                                                                                                                        45
                                                          also discussed.                                                                                                                                                                                                                                                            for developing the disorder.  Multicomponent CBT showed 
                                                                                                                                                                                                                                                                                                                                     promise in a group of male combat veterans with severe and 
                                                          Methods                                                                                                                                                                                                                                                                    chronic PTSD for improving social functioning beyond that 
                                                          A literature search was conducted in electronic data-                                                                                                                                                                                                                      provided by exposure therapy alone, particularly by increas-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   46
                                                          bases, including PubMed, for articles on CBT and PTSD.                                                                                                                                                                                                                     ing social engagement and interpersonal functioning.  CBT 
                                                          Search with key terms of (“cognitive behavior therapy”                                                                                                                                                                                                                     with brief virtual reality exposure has been found to be 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                45
                                                          OR CBT[All Fields]) AND (“stress disorders, post-                                                                                                                                                                                                                          beneficial in treating PTSD in war veterans.  A 12-session 
                                                          traumatic” [MeSH Terms] OR (“stress” [All Fields] AND                                                                                                                                                                                                                      integrated treatment using components of cognitive process-
                                                           “disorders” [All Fields] AND “post-traumatic” [All Fields])                                                                                                                                                                                                               ing therapy for PTSD, and CBT for chronic pain management 
                                                          OR  “post-traumatic stress disorders” [All Fields] OR                                                                                                                                                                                                                      in veterans with comorbid chronic pain and PTSD, suggested 
                                          For personal use only.“PTSD” [All Fields]) resulted in 192 articles representing                                                                                                                                                                                                           not only the feasibility of this treatment approach but also 
                                                                                                                                                                                                                                                                                                                                                                                                      47
                                                          58  randomized controlled trials. A further manual search                                                                                                                                                                                                                  clinical benefit.
                                                          found seven further randomized controlled trials in the rel-
                                                          evant area. Studies that did not include patients with PTSD                                                                                                                                                                                                                Sexual assault
                                                          or CBT, or were not relevant to the topic, were excluded.                                                                                                                                                                                                                  There is evidence that CBT is successful in reducing the 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          32,48,49
                                                          This left 31 randomized controlled trials involving CBT in                                                                                                                                                                                                                 symptoms of PTSD following assault on females, rape,                                                                                                                                                                                                        
                                                                                                                                                                              11–41                                                                                                                                                                                                                                                                       33
                                                          PTSD patients (see Table 1).                                                                                                         In addition, manual searches                                                                                                          and childhood sexual abuse.  It has been observed that these 
                                                          were conducted for relevant articles in specific areas for a                                                                                                                                                                                                               gains could be maintained in the long term at follow-up 
                                                          comprehensive review. While the randomized controlled                                                                                                                                                                                                                      assessments.32,48 A study comparing prolonged exposure 
                                                          trials have established the efficacy of CBT in PTSD second-                                                                                                                                                                                                                alone, prolonged exposure plus cognitive restructuring, or 
                                                          ary to various types of trauma in different situations and age                                                                                                                                                                                                             wait-list in female patients with chronic PTSD following 
                                                          groups, various other studies have widened the applicability                                                                                                                                                                                                               sexual assault, found that both treatments reduced PTSD and 
                                  Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 54.191.40.80 on 03-Jul-2017and usability of CBT in PTSD. There is extensive literature                                                                                                                        depression in intent-to-treat (ITT) and completer samples 
                                                          in this area which needs comprehensive review.                                                                                                                                                                                                                             compared with wait-list. However, the addition of cognitive 
                                                          CBT for PTSD in adults                                                                                                                                                                                                                                                     restructuring did not enhance the treatment outcome. This 
                                                                                                                                                                                                                                                                                                                                     study showed that treatment by counselors with minimal 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          50
                                                          Terrorism                                                                                                                                                                                                                                                                  CBT experience was as efficacious as that of CBT experts.  
                                                          CBT has been found to be effective for PTSD following ter-                                                                                                                                                                                                                 Studies have found that CBT helps to decrease self-reported 
                                                          rorist attacks, eg, in the survivors of the 9/11 terrorist attack                                                                                                                                                                                                          PTSD severity and associated anxiety, and that participants 
                                                                                                                                                                             42                                                                                                                                43
                                                          on the World Trade Center,  the 2005 London bombings,                                                                                                                                                                                                                      do not meet criteria for a PTSD diagnosis at follow-up 
                                                                                                                                                                                                                                                                                                               44                                                                                                                                                                                                                        32,33
                                                          and the 1998 bomb explosion in Omagh, Northern Ireland.                                                                                                                                                                                                                    assessments, showing sustained improvement.
                                                          CBT for the victims of the World Trade Center attack was 
                                                          manualized, applied flexibly, in 12–25 sessions, by therapists                                                                                                                                                                                                             Road traffic accidents
                                                          with no prior training through to extensive training in CBT.                                                                                                                                                                                                               Motor vehicle accidents are common precipitants of PTSD. 
                                                          There were significant pre-post reductions in symptoms                                                                                                                                                                                                                     There is evidence for efficacy of trauma-focused CBT for 
                                                                                                                                                                        42                                                                                                                                                                                                                                                                                                                      18,51
                                                          of PTSD and depression.  The improvement in PTSD in                                                                                                                                                                                                                        motor vehicle accident-related PTSD.                                                                                                                                      CBT elements, like 
                                                          168                                   submit your manuscript | www.dovepress.com                                                                                                                                                                                                                                                                                 Neuropsychiatric Disease and Treatment 2011:7
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                                                                                                   Findings/outcome         u         a                                h                                                                                                                                l                                                                                                         ffective CBT treatment of PTSD may be accompanied by adaptive changes in 
                                                                                                                 Brief earl b         b         of incident had significantlAt     better in the dimensional No differences in efficacy were detected between CBT and structuParticipants in both CBT conditions had significant reductions in substance use, PTSD, and psychiatric symptoms, but community care participants worsened over time. CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance.Nonsignificant improvements in the CBT group, with a significant Cacute unscheduled cardiovascular events and high baseline PTSD symptoms. CBT thatincludes imaginal exposure is safe.Telephone CBT completers reported fewer illness-related PTSD symptoms, including less avoidance (after controlling for covariates. These results were consistent in follow-ups.CBT treatment proved to be highly effective in terms of PTSD symptom reduction, showed increases in post-traumatic growth subdomains “new possibilities” and “personal strength”.easymmetrical brain function.Greater decrease in heart rate reactivity for CBT than for rate reactivity was associated with clinical improvement.Greater improvement in the CBT group as compared with the (effect size d(post-treatment) and 76% at 3One-year results showed a continued significant advantage on categorical diagnosis (PTSD or not) and structured interview measures for CBT over SP.Group CBT showed significant reductions in PTSD symptoms, both in clinical interview and self-report measures. Among treatment completers, 88.3% of group CBT relative to 31.3% of the minimum contact comparison participants did not satisfy criteria for PTSD at post-treatment. Treatment gains were maintained over a 3-month period. Patients reported satisfaction with Group CBT.CBT was superior to at 3
                                                                                                                                                                                                            
                                                                                                                                                                                                                       
                                          For personal use only.                                                                                                                                                                                                                                                                                                                                                                                                                                                            
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                                                                                                   Comparator    w                                          Rogerian ST                        Structured writing therapyManualized CBT addressingonly substance abuse,standard community careTAUducational sessions only
                                                                                                                                                                                                                                                                                             e                                             Assessment only condition           w                                  w                      w                       w                                  SP                     Minimum contactcomparison group                            SP, 
                                  Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 54.191.40.80 on 03-Jul-2017
                                                                                                   Therapy       Brief CBT                                  CBT                                CBT         Manualized CBT addressing both PTSD and substance abuseCBT                        CBT using imaginal exposure                   Telephone CBT                       CBT                                CBT                    CBT                     CBT                                CBT                    Group-CBT                                                  CBT
                                                                                                                                                                                                            
                                                                                                                                                                                                                                               
                                                                                                                                                                                                                                                                                                                                            
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                                                                                                                                                                                                                                                                                                                                                                               A                                  A                      A                       A                                  A                      A                                                          A with chronic PTSD
                                                                                                   Trauma/contextAcute PTSD fr                              Chronic PTSD                       PTSD patients in outpatient clinicComorbid PTSD and substanceuse disorders in womenComorbid PTSD in severemental illnessCardiovascular illnessHematopoietic stemcell transplantationv                              v                      v                       v                                  v                      v                                                          v
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                                                                                   Randomized controlled trials involving cognitive-behavioral therapy in patients with post-traumatic stress disorder
                                                                                  Table 1          Reference     11                                         12                                 13          14                                 15                                             16                                            17                                  18                                 19                     20                      21                                 22                     23                                                         24
                                                                            Neuropsychiatric Disease and Treatment 2011:7                                                                                                                                                                                                                                                                                                                                       submit your manuscript | www.dovepress.com                                                                                       169
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                                                                                                                                                          months.                                                                                                                                                                         e                                                                                            a                                                                                                                                            M
                                                                                                                                                                                                                                                                                                                                          d          r                                                                                 c                                                                                                                               e e
                                                                                                                                                                                                                                                                                                                                                     e                                                                                 fi                      greater 
                                                                                                                                                                                                                                                                                                                                          n          t                                                                                 i                                                                                                                                                      L, waitlist control.
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                                                                                                                                                                                                                                                                                                                                                     a                                                          nitial trial of TF-CBT was suggested for most children 
                                                                                                                                                                                                                                                                                                                                          r          c                                                          i                      T                                                                                                                                            intent-to-treat; 
                                                                                                                                                                                                                                                                                                                                          o          fi                                                                                B                       significantly 
                                                                                                                                                                                                                                                                                                                                          i          i                                                                                 C
                                                                                                                                                                                                                                                                                                                                          r          n                                                                                 -
                                                                                                                                                                                                                                                                                                                                          e          g                                                                                 F                                                                                                                                            TT, 
                                                                                                                                                                                                                                                                                                                                          p          i                                                                                                                                                                                                                              i
                                                                                                                                                                                                                                                                                                                                          u          s                                                                                 T
                                                                                                                                                                                                                                                                                                                                          s                                                                                                                                                                                                                 otocol was both statisticall
                                                                                                                                                                                                                                                                                                                                                     a                                                                                 h
                                                                                                                                                                                                                                                                                                                                                                                                                                       t
                                                                                                                                                                                                                                                                                                                                          e          d                                                                                 i                                                                     L; maintained at 3-month follow-up for both interventions.
                                                                                                                                                                                                                                                                                                                                          r          a                                                                                 w
                                                                                                                                                                                                                                                                                                                                          e          h                                                                                                         evidenced                                     w                       1.40) and had sustained treatment effects. A stable and positive 
                                                                                                                                                                                                                                                                                                                                          w                                                                                            d                                                                                              
                                                                                                                                                                                                                                                                                                                                                     T                                                                                 e                                                                                             =
                                                                                                                                                                                                                                                                                                                                          T          B                                                                                 t                                                                                              
                                                                                                                                              months. One-third of those who completed self-management CBT                                                                                                                                                                                                                             a
                                                                                                                                                                                                                                                                                                                                          C          C                                                          sertraline group.      e                                                                                                                                            reprocessing; 
                                                                                                                                                                                                                                                                                                                                          P                                                                                            r                                                                                                                    eatment pr
                                                                                                                                                                                                                                                                                                                                                     .                                                          +                      t
                                                                                                                                                                                                                                                                                                                                          d          s                                                                                                                                                                                                                              and 
                                                                                                                                                                                                                                                                                                                                          n          e                                                                                 n
                                                                                                                                                                                                                                                                                                                                          a          r                                                                                 e
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                                                                                                                                                                                                                                                                                                                              months post assault, all three interventions had generally similar outcomes.Be                           i
                                                                                 Findings/outcomeRelevance of a brief focused intervention comprised of CBT and exposure was established; the need to eliminate barriers to treatment retention was associated with income and education.Self-management CBT led to greater reductions in PTSD, depression, and anxiety scores at 6achieved high end state functioning at 6xposure therapy and CBT led to a 48% and 53% reduction on PTSD symptoms,  ndividual TF-CBT was effective for PTSD in children and young people.hnternet-based CBT proved to be a treatment alternative for PTSD rauma tr
                                                                                                                                                                      e          respectively, with no difference between them on any measure; results were maintained at the 6-month follow-up.Reduction of PTSD severity by CBT was significantly mediated by improvement in orthostatic panic and emotion regulation ability.Substantial gains were achieved by adding CBT to pharmacotherapy for PTSD.Significantly greater improvement in the initial treatment condition, with large effect sizes for all outcome measures.Community TF-CBT effectively improves children’s PTSD and anxiety related to intimate partner violenceAt postintervention, and at 3-month follow-up, participants in brief CBT reportedgreater decreases in self-reported PTSD severity than those in SC; however around9Cmand PCT were associated with sustained symptom reduction.iSignificant improvement in both groups with no significant differences between groups except in Child Global Assessment Scale ratings, which favored the TF-CBTwith PTSD before adding medication.Cless shame than the children who had been treated with CCT at 6 and 12TF-CBT group follow-up.CBT compared with CCT, demonstrated significantly more improvement in PTSD.Symptom reductions were similar in magnitude with CBT and acupuncture compared with i(effect size donline therapeutic relationship could be established.Tand this was maintained and became mor
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    desensitization 
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                                                                                                                                                                      xposure therapy                    L                                                                                                                                                                   L                                                                                                                                           L                                  MDR
                                                                                 Comparator    TAU                                SC                                  e                                  w                      Sertraline alone        Delayed treatment(crossover trial)Usual care (CCT)Assessment condition, SC        Problem-solving therapy(present-centeredtherapy; PCT), wTF-CBT                               CCT                     Nondirective supportivetherapy (NST)CCTAcupuncture,       w                                  e                       therapy; 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       otocol)      child-centered 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    CCT, 
                                                                                                                                                                                                                                                                                                                                                                                         sertraline                                                                                                                                                                    eatment pr
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    distress; 
                                                                                                                                                                                                                                                                                                                                                                                         +
                                                                                                                                                                                                                                                                                                                                                                                          
                                  Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 54.191.40.80 on 03-Jul-2017
                                                                                 Therapy       Cognitive-behavioral exposure treatmentSelf-management CBT             CBT                                Culturally adapted CBT CBT with sertraline     Culturally adapted CBT, initial treatmentTF-CBTBrief CBT                          CBT                                TF-CBT      TF-CBT                                        TF-CBT                  TF-CBT                 TF-CBT      Group CBT              nternet-based CBT
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         i                                  CBT variant(trauma tr   postdisaster 
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                                                                                                                                                                                                                                                        e                                                                                                                                                                                                                                                                                                                           therapy 
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                                                                                                                                              raq war                                                                                                   m
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                                                                                               TC disaster workers                                                                                                                                      t
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                                                                                                                                                                                                                                                        f                                                                                                                                                                                                                                         arious trauma
                                                                                 Trauma/contextPTSD in                            PTSD in service membersfollowing 9/11 or Refugees                      Refugees with pharmacology-resistant PTSDRefugees with pharmacotherapy-refractory PTSDentimate partner violence                                                                                                                                                                                                 arious trauma                      arious trauma
                                                                                                                                                                                                                                                        R          PTSD and panic attacksi            Female survivors of assault         Female survivors of childhoodsexual abusePTSD in children and adolescentsSexually abused childrenSexually abused childrenSexually abused childrenSexually abused childrenv     v                                  v                       CBT-PD, 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
                                                                Continued
                                                                 (
                                                                Table 1          Reference     25                                 26                                  27                                 28                     29                      30                     31                     32                                  33                                 34         35                                             36                      37                     38          39                     40                                 41                      Abbreviations:stress disorder; SC, supportive counseling; SP, supportive psychotherapy; ST, supportive therapy; TAU, treatment-as-usual; TF-CBT, trauma-focused cognitive-behavior therapy; 
                                                          170                                   submit your manuscript | www.dovepress.com                                                                                                                                                                                                                                                                                 Neuropsychiatric Disease and Treatment 2011:7
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...Neuropsychiatric disease and treatment dovepress open access to scientific medical research full text article review cognitive behavioral therapy for the of post traumatic stress disorder a nilamadhab kar background ptsd is psychiatric sequel stressful department psychiatry event or situation an exceptionally threatening catastrophic nature wolverhampton city primary cbt has been used in management many years this paper reviews care trust uk effectiveness following various types trauma its potential prevent methods reflects on mechanisms action electronic databases including pubmed were searched articles manual searches conducted cross references relevant journal sites results current literature reveals robust evidence that safe effective inter personal use only vention both acute chronic range experiences adults children adolescents however nonresponse by can be as high contributed factors comorbidity study population validated across cultures successfully community therapists brief t...

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