Beliefs, Self-focus, and Behavior Related to PTSD

In a recent Beck Institute Workshop, Dr. Aaron Beck explains how negative beliefs, points of focus, and behavior play a role in the development of PTSD. He gives an example describing how one’s focus can lead to either an activation of negative beliefs or to adjustment.

Join us for our specialty workshop on CBT for PTSD. For more information visit our website.

Dissemination of Evidence-Based Treatments for PTSD: Barriers and Accomplishments

Posttraumatic stress disorder (PTSD) presents as a significant public health challenge because of its pervasive effects on mental health, physical health, and psychosocial problems. A recent review published in Psychological Science in the Public Interest, evaluates the effectiveness of prolonged exposure (PE) and cognitive behavior therapy (CBT) for individuals with PTSD. Although studies indicate that these treatments are efficacious for various populations, many individuals with PTSD do not receive evidence-based treatments (EBTs). The present review investigates barriers to be addressed in order to promote dissemination of EBTs for PTSD in developed and developing countries. Specifically, the authors review examples of dissemination models, discuss possible solutions, and suggest future steps in disseminating EBTs for PTSD. Improved dissemination of EBTs for PTSD is necessary in order to increase accessibility of successful treatments.

Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: Lessons learned from prolonged exposure therapy for PTSD. Psychological Science in the Public Interest, Supplement, 14(2), 65-111.

Pretreatment Predictors of Dropout in War Veterans Receiving CBT for PTSD

Although research suggests that cognitive behavior therapy (CBT) is rather efficacious in the treatment of posttraumatic stress disorder (PTSD) symptoms, CBT also appears to be limited by high rates of treatment attrition. A recent retrospective study published in Psychological Services examined differences between war veterans (Iraq and Afghanistan) who completed treatment versus those who dropped out of treatment.

Participants (N = 117) in the present study received outpatient CBT treatment for PTSD at a PTSD specialty clinic. Their clinical data was evaluated, and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) was utilized to predict treatment dropout. Dropout was defined as ending treatment before attaining the predetermined treatment goals set by the client and clinician.

According to results, approximately 68% of participants dropped out of treatment. Younger war Veterans were more likely to drop out from treatment than older veterans. Additionally, patients with high scores on MMPI-2 TRT scale, which measure discomfort with discussing problems and negative attitudes toward mental health treatment, were also more likely to drop out of treatment. Notably, war veterans who completed treatment showed reductions in PTSD symptom severity. These results suggest that age and negative attitudes toward mental health services can help predict treatment adherence in war veterans seeking treatment for PTSD.

Garcia, H. A., Kelley, L. P., Rentz, T. O., & Lee, S. (February 01, 2011). Pretreatment Predictors of Dropout From Cognitive Behavioral Therapy for PTSD in Iraq and Afghanistan War Veterans. Psychological Services, 8, 1, 1-11.

Evidence-Based Treatment Approaches for Troops with PTSD

Nearly 20% of the 2.6 million troops deployed to Afghanistan and Iraq report symptoms of posttraumatic stress disorder (PTSD). PTSD is associated with hyperarousal, avoidance, and disturbing or reoccurring flashbacks, all of which affect mental and physical health.

The Department of Defense (DoD) and Veterans Affairs (VA) have recommend four treatment approaches for PTSD: Prolonged Exposure (PE) Therapy, Cognitive Processing Therapy (CPT), Stress Inoculation Therapy (SIT), and Eye-Movement Desensitization and Reprocessing (EMDR) Therapy. While there has been little empirical research indicating that EMDR and SIT are effective for PTSD, there is considerable research supporting the effectiveness of both PE and CPT. As a result, the VA has mandated that PE and CPT be available to all patients with PTSD. PE uses imagined and in vivo exposure to help patients confront trauma-related stimuli and extinguish fear responses. CPT targets trauma-related maladaptive cognitions by exposing patients to their own thoughts as they write about their traumas. According to the current review, four randomized control trials (RCTs) support the efficacy of PE for military-related PTSD and one RCT and one uncontrolled effectiveness study provide initial support for the efficacy of CPT in treating military-related PTSD.

Even though the VA has mandated PE and CPT for veterans and military service men and women with PTSD, it is important for clinicians who work with this population (both within and outside the VA) to educate their clients about evidenced based treatment to promote retention and recovery.

Steenkamp, M. M., & Litz, B. T. (February 01, 2013). Psychotherapy for military-related posttraumatic stress disorder: Review of the evidence. Clinical Psychology Review, 33, 1, 45-53.

CBT Helps Prevent Soldiers from Developing Symptoms of PTSD

Research indicates that 4.3% of troops develop PTSD upon returning from combat. A recent epidemiological study published by the Digital Access to Scholarship At Harvard describes a program launched by the Department of Veterans Affairs (VA) in an effort to reduce the risk for post-traumatic stress disorder (PTSD) in post-war veterans. This initiative ensures that all combat veterans, regardless of occupational rank, will receive evidence-based cognitive behavior therapy (CBT) upon returning from war.

In the current study, American, British, and Dutch authorities administered a number of epidemiological surveys to post-war veterans. These surveys were designed to evaluate the mental health status of veterans upon returning from the wars in Iraq and Afghanistan. Results of these surveys showed tense, irritable, and depressive-like symptoms among these soldiers, therefore making many of them candidates for CBT treatment. Participants in the study received either prolonged exposure (PE) treatment, which requires patients to recount traumatic memories repeatedly within a structured, supportive therapeutic context until distress declines, or cognitive processing therapy (CPT) which requires patients to write continuously about their traumatic experience. Of the 66% of veterans who completed the PE program, 74% had post-treatment scores that fell below the cutoff for PTSD.

Since this study, the Army has also developed a number of methods to prevent soldiers from developing symptoms for PTSD. One post-deployment early intervention program, Battlemind Debriefing, focuses on preparing soldiers with the specific skills they need to transition from combat zone to home. The Army has also developed similar training programs for larger groups transitioning from home to combat units. These programs teach soldiers “emotional bonding skills” that are useful to their specific combat unit. Rather than having soldiers focus on the traumatic events they have experienced, these programs focus on strengthening their family relationships and coping skills. According to the author, the prospects for resiliency and recovery from PTSD are at their current highest, as VA is ensuring evidence based treatment. Still, the “surest route to preventing PTSD in the world is to further the global decline in violence” (McNally, 13).

McNally, Richard J. (2013). Are we Winning the War Against Posttraumatic Stress Disorder? Digital Access to Scholarship at Harvard. Science 336 (6083). 1-16.

Identifying Suicide Risk

In this video from a recent CBT workshop at the Beck Institute, Dr. Aaron Beck describes ways to identify a person at risk for suicide. He discusses immediate risk factors (such as those shown through the use of predictive scales), peripheral risk factors, and demographic risk factors. Dr. Beck also discusses his previous research involving the post-attempt suicide ideation scale and important findings from that research.

Beck Institute’s next CBT for Depression and Suicidality Workshop will take place July 15-17, 2013. For more information, visit our website.

CPT is Effective for Military-Related PTSD

According to a recent study published in the Journal of Anxiety Disorders, cognitive processing therapy (CPT) may have a greater effect on military-related PTSD than other usual treatments. CPT is a form of trauma-focused cognitive behavior therapy (CBT) that focuses on key themes such as safety, control, power, self-esteem, and intimacy. The present study examines the efficacy of CPT for PTSD among treatment seeking veterans (n=59) within a naturalistic setting compared to other treatments typically used for PTSD (a variety of non-trauma focused symptom management intervention, psycho-education, supportive counseling, and CBT with elements of exposure.) At post-treatment and 3 month follow up, participants in the CPT condition (n=30) showed significantly lower levels of PTSD symptoms than those who received other treatments (n=29) according to self -reporting and clinical ratings.  Additionally, there were larger reductions in comorbid depression and anxiety for participants receiving CPT than treatment as usual. These results suggest that CPT is an effective, evidence based treatment for military-related PTSD in real world environments and situations.

Forbes, D., Llyod, D., Nixon, R. D. V., Elliot, P., Varker, T., Perry, D., Bryant, R. A., & Creamer, M. (2012). A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder. Journal of Anxiety Disorders, 26(3), 442-452.

Long Term Effects of CBT for PTSD

According to a recent study published in the Journal of Consulting and Clinical Psychology, cognitive-behavior treatments (CBT) may provide long-term improvements for PTSD and related symptoms. CBTs such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) have already been shown to be effective and are considered some of the “first line treatments” for PTSD. However, the important question of CBT’s long term efficacy for PTSD has not been explored as deeply, as follow ups typically occur only three to six months after treatment.

The current study compares the long term outcomes of CPT and PE for PTSD in female rape survivors. The original study measured symptoms of women suffering from PTSD (n=171), before and after receiving either CPT or PE. This long term follow up, from 4.5 to 10 years later (M = 6.15), includes 73.7% of the original sample following initial treatments (n= 126) of CPT (n= 63) or PE (n=63). Researchers used the PTSD Symptom Scale (PSS), the Beck Depression Inventory (BDI), and the Clinician-Administered PTSD Scale (CAPS) to measure PTSD symptoms. Of those allocated to CPT, 46 completed the therapy, 10 received some therapy, and 7 did not start. Of those allocated to PE, 44 completed the therapy, 13 received some therapy, and 6 did not start.

Participants who received both cognitive therapies (CPT and PE) showed significant improvements in PTSD and related symptoms from pre- to post-treatment. There was no marked significance in the difference between the two samples receiving treatment. During the long term follow up, there was an impressive amount of maintenance of these improvements in symptoms. At pre-treatment assessment, 100% of participants had met criteria for PTSD; however, at the long term follow up only 22.2% of participants in the CPT group and 17.5% in the PE group met criteria for PTSD. In addition, there was no further psychotherapy or medication use reported which could have otherwise accounted for the long term efficacy of these treatments.

Female rape survivors in this study benefitted significantly from a lasting improvement in PTSD symptoms. Although further research and replication studies are needed, these findings suggest that CBT may be effective for years following initial treatment.

Resick, Patricia A., Williams, Lauren F., Suvak, Michael K., Monson, Candice M., & Gradus, Jaimie L. (2012). Long-term outcomes of cognitive–behavioral treatments for posttraumatic stress disorder among female rape survivors. Journal of Consulting and Clinical Psychology, 80(2) 201-210.


Beck Institute will offer a 3-day workshop on CBT for PTSD on September 10-12, 2012, in Philadelphia. A limited number of spaces remain.

Cognitive Behavior Therapy is Effective for Sleep Disturbances in US Military Vets

According to a recent study published in the Journal of Psychosomatic Research, cognitive behavior therapy (CBT) may improve sleep and reduce daytime PTSD symptoms among military veterans. The current study compared Prazosin (a pharmacological treatment for sleep disturbance) versus a CBT sleep intervention against a placebo control. Fifty US military veterans were randomly assigned to either the Prazosin group (n = 18), the CBT group (n = 17), or the placebo group (n = 15). Both active groups (Prazosin and CBT) showed greater reductions in insomnia and daytime PTSD symptom severity. Overall sleep improvements were noted in 61.9% of those who completed the active treatments and 25% of those in the placebo group. These results suggest that both pharmacological and CBT interventions may improve sleep and reduce PTSD symptoms among military veterans.

Germain, A., Richardson, R., Moul, D. E., Mammen, O., Haas, G., Forman, S. D., Rode, N., … Nofzinger, E. A. (2012). Placebo-controlled comparison of prazosin and cognitive-behavioral treatments for sleep disturbances in US Military Veterans. Journal of Psychosomatic Research, 72, 2, 89-96.