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Neuropsychiatric Disease and Treatment Dovepress
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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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Dovepress CBT for PTSD
t )
h n
t e s h
i h m t
w t t a i
ention, n a w w
v s o e
t r T s
n m t t
e B n Continued
i t n e (
t s i C i
a t
p r s . a 0.05) even
fi t s p
, n r
r e e e f ,
e h i t o
v t t e P L group
e a l red writing therapy. improvement inp
w n p p
eek post inter i u w
o h e m o
t r L. The change in heart
H i r o g
o c
. w b L. Results maintained
s m e u w
h d h s
t e y t w
n d l a
o u t n
l n i n
m c a i
c T
n s
4 i months. fi S
i m
t e n f
a r g o o
e i t
t s e p
n w s
a es at 4 d o m
c o e h y
fi h n t s
er symptoms at one wi i
w n w a o D
g t t
e i d e S
s r t
n T
y f t a n P
o T e
n n B l n
o a i
d i C v
n s i d months in the CBT group.
a s er PTSD score u n
e r q a 0.001) and fewer intrusive thoughts (
r r w e e
e p h y ,
l e t
l e r TT analysis at post test. i
a d y lo w i r P
e e L and to SP; SP was superior to
m r y w v
s o d e w
j u s S
s a t t -
a s c e
w m e l
oup had significantl p f a
d f
e i u e c
c b - S 1.61). Categorical diagnostic data indicated clinical recovery of 67%
n r s
w t l =
e o o i a
r l b
e m l t o
f o u l
f o f
y CBT gr i c b
d r G
,
e e a T mprovement was maintained at 6- and 9-month follow-ups. l
n e S i a
h i c months.
t l y i
e - n n
t s 2 a i
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.
L
L L L L L w
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,
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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
om various trauma
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
M M M M M M M
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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T d
B e
b
y i
r C r
a c
d h s
n t e
o d 12-month
o B
c d
e . n e in PTSD; post-traumatic
s L a months. the
.
d W D at
n S ectiv
a d PTSD,
n T
s a P w-up
e eff
m T f
o o PTSD
t C ollo
p P s in
m m y mor
y n o accidents;
s a t
h p
t
D m
S e y
T t s vehicle
a y 3-month f
P r r
e
g t
n u w
i o e improvement y and clinicall
s f motor
a p
o y
e l A,
r r t vident b v
c d n
months. e a M
d r c e e
e fi greater
n t i L, waitlist control.
i a n
e g
L r i w
g s
w y d
l a
o t h
t n
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
u r
s d
T a l
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
For personal use only. L L
w w movement
placebo eye
+
MDR,
e
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;
+
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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
t for
n
a
t
s
i
s
e therapy
r l
-
t
n
e
raq war m
i t
a behaviora
e
r
t
h
TC disaster workers t
i
w w
cognitive
s
) e
e
g
u
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;
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