Elsevier

Aggression and Violent Behavior

Volume 5, Issue 1, January–February 2000, Pages 79-97
Aggression and Violent Behavior

Cognitive behavioral therapy of violence-related posttraumatic stress disorder

https://doi.org/10.1016/S1359-1789(98)00021-4Get rights and content

Abstract

Posttraumatic stress disorder (PTSD) represents the most common psychiatric condition following exposure to violence. Although an increasing number of cognitive behavioral therapy (CBT) studies point to efficacy of this approach in ameliorating PTSD following violence, the methodological rigor of many studies has not been optimal. Further, a significant proportion of traumatized individuals does not benefit from CBT. This article reviews CBT outcome studies, discusses the methodological limitations of CBT studies for PTSD, and offers suggestions for future research. This review highlights the need for more systematic studies of components of CBT with a range of trauma populations to delineate the parameters of effective CBT for individuals with PTSD.

Section snippets

Definition of ptsd

PTSD was introduced into psychiatric nomenclature in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1980). The definition of PTSD has undergone a number of revisions, and is currently defined by DSM-IV (American Psychiatric Association, 1994). To satisfy criteria for PTSD, one must initially have been exposed to a traumatic event. In defining a trauma, DSM-IV stipulates that: “the person experienced, witnessed, or was

Incidence of ptsd following assault

Two well-controlled studies have been conducted on the incidence and course of PTSD following assault Riggs et al. 1995, Rothbaum et al. 1992. Each study prospectively assessed sexual and nonsexual assault victims during the initial 3 months following the assault. In terms of rape victims, 94% met criteria for PTSD approximately 1 week following the assault, 65% met criteria 1 month after the assault, and 47% met criteria 3 months after the rape (Rothbaum et al., 1992). A similar pattern was

Theoretical issues

Most cognitive behavioral treatments of PTSD are related to variants of information-processing theories of trauma response. Foa and Kozak (1986) adapted Lang's (1977) theory that fear is represented in cognitive networks of mental representations of fear-related stimuli, responses, and meanings. According to Foa and Kozak (1986), trauma can result in the formation of threat-oriented schema that serve to maintain a range of PTSD symptoms. It is proposed that the constant activation of fear

Systematic Desensitization

Some of the earliest studies to apply behavioral principles to trauma victims focused on systematic desensitization. This procedure, developed by Wolpe (1958), couples imagination of the feared stimulus with relaxation, and typically requires the individual to master feared scenes in a hierarchically graded regime. Frank and colleagues investigated the efficacy of systematic desensitization in a series of studies with female rape victims Frank & Stewart 1983, Frank & Stewart 1984. In these

Treatments of acute stress disorder

Considering that ASD was only introduced into DSM-IV in 1994, it is not surprising that there are few treatment studies relevant to ASD. Although there are reports of crisis intervention in the initial month(s) after a trauma being beneficial (e.g., Brom, Kleber, & Hofman 1993, Viney, Clark, Bunn, & Benjamin 1985), these are not well-controlled studies, do not utilize CBT in a structured manner, and have not adequately indexed PTSD symptoms. Kilpatrick and Veronen (1983) reported on a brief

Detrimental Effects of Exposure Therapies

There is increasing evidence that exposure-based therapies may not only be nonbeneficial for some PTSD sufferers but may even be detrimental. Kilpatrick and colleagues Kilpatrick, Veronen, & Best 1985, Kilpatrick, Veronen, & Resick 1982 have criticized flooding for sexual assault survivors because: (a) in aiming to reduce anxiety it may focus on symptom change rather than modifying irrational thoughts, (b) it may contribute to excessive noncompliance with therapy because of its distressing

Comorbidity

There is strong evidence that many people who develop PTSD will also suffer comorbid disorders. Depression, substance abuse, and anxiety disorders are among the common comorbid diagnoses in the PTSD population Davidson & Fairbank 1993, Davidson, Hughes, & Blazer 1991, Keane & Wolfe 1990. Further, there is evidence of elevated rates of personality disorders Faustman & White 1989, Southwick, Yehuda, & Giller 1993 among PTSD populations. Most cognitive behavioral treatment studies have focused

Specific populations

In recent years there has been increasing awareness that PTSD needs to be studied in specific trauma populations. The aforementioned studies of PTSD following sexual and nonsexual assault Riggs et al. 1995, Rothbaum et al. 1992 indicate that the recovery process is not identical following these related, but distinct, types of trauma. Further, Riggs et al. (1995) found different recovery rates for females and males following nonsexual assault. Specifically, whereas 70% of females and 50% of

Summary

This review has indicated that there are a number of important directions for future research of treating PTSD following violence. Most importantly, there is a need to delineate the reasons why exposure-based therapies result in only half of treatment participants enjoying good end-state functioning. Considering the heterogeneity of PTSD presentations following violent traumas (Foa et al., 1995), it is not surprising that a single intervention is not equally effective for all people. The

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