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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
which may be used in the treatment of posttraumatic stress disorder (PTSD) either alone as “types” of CBT or used in combination include exposure, cognitive restructuring, various coping skills or anxiety management, and psychoeducation (Foa et al., 2000; Friedman, 2003, Harvey et al., 2003).
Exposure is a treatment that involves confrontation with frightening stimuli and is continued until anxiety is reduced. Types of exposure include imaginal exposure, which involves exposure to traumatic event through mental imagery, either memory constructed through client’s own narrative or scene presented by therapist based on provided information (Foa et al., 2000), and in vivo, where a client confronts the actual scene or similar events in life. Most salient in this type of exposure is the “correction of erroneous probability estimates of danger and habituation of fearful responses to trauma-relevant stimuli” (Foa et al., 2000).
In exposure therapy, the client and clinician may create a “fear hierarchy,” rating feared situations in order of anxiety response; clients may be exposed to the most distressing situation or trigger (flooding) or moderately anxiety-provoking situations first (Foa et al., 2000). Anxiety management techniques are usually taught (e.g., relaxation, psychoeducation), but more time and attention are given to exposure proper (Foa et al., 2000). The client is exposed to trauma-related stimuli (imaginal or in vivo) with interruptions during which the client reports his or her anxiety level using Subjective Units of Distress Scale (SUDS) (10 [no distress] to 100 [most fear]) (Friedman, 2003). The aim is to extinguish the conditioned emotional response to traumatic stimuli (learn that nothing ”bad” will happen in traumatic events), which eventually reduces or eliminates avoidance of feared situations. Exposure therapy has received the strongest evidence for PTSD, and clinical practice guidelines recommend it as the first line of treatment unless reasons exist for ruling it out (e.g., patients who were perpetrators of harm) (Foa et al., 2000).
Cognitive therapy (CT) was originally developed by Aaron Beck in 1976 to treat depression, and subsequently developed as a treatment for anxiety (Foa et al., 2000). Beck’s (1976) theory holds that it is the interpretation of the event, rather than the event itself, that determines an individual’s mood; therefore, overly negative interpretations lead to negative mood states. CT uses cognitive restructuring techniques aimed at facilitating relearning thoughts and beliefs generated from a traumatic event and increasing awareness of dysfunctional thoughts contributing to anxiety response in