Treating PTSD with Cognitive Processing Therapy



Treating PTSD with Cognitive Processing Therapy


This research paper discusses the treatment of post-traumatic stress disorder (PTSD) with cognitive processing therapy. People suffering from post-traumatic stress experience difficulties with overcoming the consequences of a traumatic event. This condition influences their everyday life for a long time. In many cases, PTSD is accompanied by a set of symptoms, which disturb the normal life of a person. For example, a tragic event can recur in a person's memory again and again, which will make a person live through it each time that particular memory recurs. Other symptoms of PTSD include nightmares, inability to concentrate, and a constant feeling of anxiety.

This paper discusses PTSD symptoms and statistics related to a disorder. Moreover, it touches upon various kinds of PTSD therapeutical treatments like Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy, and EMDR Therapy. A therapist should use both therapies for better treatment of PTSD. It is necessary to synthesize and integrate existing therapies to apply them in treatment. The paper is well-organized and provides a comprehensive discussion on the topic covered. The paper consists of 15 pages. 14 peer-reviewed articles were used while writing this research paper.

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PTSD is a type of mental disorder, which can develop after overcoming a trauma, especially if a person feels that his life is threatened. Even if a person was not wounded, he still can develop PTSD, for example, if he was threatened by death or was a victim of violence. Such a type of mental disorder often affects soldiers who cannot forget events of battles.

However, there are also other people who develop PTSD, for example, victims of serious crimes, witnesses who survived accidents, natural disasters, or acts of terrorism. PTSD can constantly cause bad memoirs, which are bright and distinct and can disturb the memory of an accident. The majority of people with PTSD have problems with sleep. They experience feelings of estrangement, fault, paranoia, and sometimes panic fears that they can be attacked again. People with PTSD are in a group of risk of committing suicide (Brewin, 2005).

In most cases, the experienced event remains in people's consciousness for some time, but it gradually disappears and allows a person to return to a normal life. Support of a family and friends is thus very important. At the same time, quite a big number of people experience post-traumatic symptoms, which over time transform into post-traumatic stress disorder (PTSD).

Treatment of PTSD is directed at the reduction of signs of fear and prevention of future problems. General signs of PTSD include recurring bright and distinct memories of an accident, avoidance of places and similar situations where the incident occurred, inability to remember or discuss incident details, alienation, emotional catalepsy, desire to be along, unstable mental condition, problems with sleep and lack of attention. Mental disorder can be diagnosed 1 month later after a trauma, though in certain cases symptoms do not develop within many months or years after the trauma occurred. The majority of people experience symptoms of PTSD for about three months. Some people experience these symptoms from time to time (Brewin, 2005).

What is PTSD

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Clinical Manifestations of PTSD

Post-traumatic stress disorder (PTSD, “the Vietnamese syndrome”, “the Afghan syndrome”, “the Chechen syndrome”) is a psychological condition, which results from psycho-traumatic situations going beyond usual human experience and menacing physical integrity of a subject or other people. It has prolonged influence, has a latent period, and can be manifested during the period from 6 months up to 10 years and more after a single or repeating psychological trauma. As claimed by Bisson "chronic post-traumatic stress disorder (PTSD) is a common disorder that people may develop after exceptionally threatening and distressing events. Psychological treatments from various theoretical perspectives have been found to be effective for chronic PTSD" (2007).

PTSD disorder is characterized by repeating and persuasive reproduction of a traumatic event in consciousness. Stress experienced by the patient is exceeded by what he felt at the time of the actual injuring event and is often extremely emotionally intensive experience causing thoughts of a suicide in a person with a purpose to escape emotional pain. Repeating nightmares and flashbacks are also a characteristic of PTSD.

The patient with PTSD avoids thoughts, feelings, or conversations connected with trauma as well as actions, places, or people who provoke these memories. PTSD is characterized by psychogenic amnesia. where the patient cannot reproduce a traumatic event in memory in detail. The patient also experiences constant vigilance and is in a condition of continuous expectation of threat. The condition is often complicated by somatic frustrations and diseases generally of nervous, cardiovascular, digestive, and endocrine systems.

Symptoms of PTSD

Post-traumatic stress disorder (PTSD) is a severe and dangerous condition for a person who experiences it as well as for people surrounding that person. Reminiscences of trauma constantly pursue the patient. Knowledge of various symptoms of PTSD will help people understand whether they have this illness or not. There exist methods of treatment of PTSD that proved to be effective, and there are no reasons for a patient to suffer alone. The symptoms of a post-traumatic stress disorder (PTSD) can be subdivided into three main categories:

  1. Repeated experiences.
  2. Refusal to perceive reality.
  3. Hypererethism.

According to Bradley (2005), repeated experiences include realistic memories of a trauma, which include pictures and memories that recur again and again in the memory of a patient and cause strong depression and despondency. Patients also suffer from regularly repeating frequent nightmares about a trauma, which make them experience it again and again. This creates a constant feeling that a traumatic event did not finish.

Patients also have feelings of depression and anxiety provoked by the objects or situations. which are somehow connected with trauma or symbolize it. Refusal to perceive reality includes such manifestations as avoidance of thoughts, feelings, and conversations connected with trauma, places, activities, and people reminding of trauma, loss of interest in activities, which seemed attractive earlier, feeling of alienation and detachment from surrounding people, difficulty to feel and express positive emotions, for example, love or happiness, unwillingness to think and speak about the future.

Hypererethism is represented by sleep disorders, irascibility, bursts of anger, difficulties with concentration and study, constant feeling of readiness for something bad, sharp reaction to loud sounds, and sudden movements.

Minor symptoms include a recurring sense of guilt connected with the consequences or behavior during a traumatic event, continuous repetition of memories of a traumatic event, and incessant thoughts of trauma. Furthermore, all interests are reduced only to questions connected with trauma, splitting of personality, and the feeling of isolation from oneself.

PTSD and Military Personnel

Military stress is an etiological factor of psychosomatic pathology among participants of war. Participation in military actions is a stressor, which is traumatic for practically any person. Unlike other stressors, participation in war is prolonged psychological traumatization.

According to Monson (2006), participation in war activities is always accompanied by a complex influence of several factors:

  • a realized feeling of threat for life, so-called “biological fear” of death, wound, pain, and invalidation;
  • incomparable stress arising among people, who directly participate in military actions; there is psycho-emotional stress caused by deaths of comrades and by a need to kill opponents;
  • influence of specific factors of a fighting situation (deficiency of time, acceleration of the rates of actions, suddenness, uncertainty, novelty);
  • deprivations (lack of full-time sleep, special water, and food modes);
  • specific climate (for example, hot climate in the mountain and desert district in Afghanistan leads to hypoxia, heat, and increased perspiration).

There are two types of causes of military PTSD. First of all, it is s psychological trauma, which has caused noticeable stressful changes in mental and physical conditions and obvious violations of behavior (aggression, panic escape, catalepsy, etc.). Other reasons for developing PTSD include the inability of people who successfully participate in fights to re-adapt to a peaceful life. Repeated traumatization is a reason for the renewal of PTSD after a quiet latent period. Negative attitudes of surrounding people, medical personnel, and social workers can also become a reason. It happens because they have a peculiar psychological complex in the form of an extra mental protest against the opportunity emergence of the same illness.

Research on fighting stress showed that the process of fighting PTSD after a war is more complicated and takes longer than PTSD in peacetime because of cumulative stress and memory of repeatedly endured horrors of war, physical and mental overstrain, grief over the loss of comrades, and empathy to the wounded. During military operations, constant disturbing vigilance and readiness for instant aggressive activities of the enemy are formed. Thus, the perception of the value of human life and responsibility for aggression decreases.

Long-term studies show that after fighting traumatic psychological stress participants of military operations should recreate in new to the conditions of peaceful life. They need to restructure their personal space, including the structure of their self-perception, self-assessment, and life orientations (Monson, 2006). According to Chard "the current wars in Iraq and Afghanistan are producing large numbers of veterans who have experienced a variety of combat stressors. The potential impact of combat exposure has been established, including significant rates of posttraumatic stress disorder (PTSD)" (2010).

Long stay of soldiers in a zone of fights becomes an important psychological injuring factor. It was found out that after 6 months of stay in a fighting environment, 20,3% of soldiers develop adaptive abilities of personality. Fighters become resistant, alert, and capable to successfully resist the opponent. Statistics show that about 42.6% of soldiers have no noticeable emotional and behavioral changes. However, 36.1% have “a permanent social and psychological disadaptation”. A stay of more than a year in a fighting situation leads to “personal disadaptation” in 83.3% of soldiers.

The probability of developing chronic consequences after fighting mental trauma directly depends on the severity of the transferred stress influence and duration of stay in battlefield conditions. Findings show the following percentages: the second year of the war – 5.5%; the third year of the war – 4.3%; the fourth year of the war – 2.4%. The second group includes exogenous psychoses. Psychoses connected with a heavy loss and somatic exhaustion are frequent in this group. The second year of the war – 6.9%, the third – 7.2%, the fourth year – 4.6%.

PTSD and Children

Children can also experience PTSD. They can show additional signs, for example, bad behavior, or they can act out the trauma, and it will emerge even more distinctly in their memory. Many children cannot tell a doctor about the trauma because of the inability to speak at the time of stress or due to a loss of speaking skills as a result of an incident. Reactions of fear and shame arising because of the distorted processing of traumatic experience block the desire of children to share the experienced violence. In certain cases, children lose trust in adults because of what happened to them, and thus communication with older people becomes a triggering factor for anxiety.

Children with PTSD can feel constant anxiety after they experience a traumatic event. Wars, tortures, rapes, natural disasters (for example, earthquakes and hurricanes), and also fires and road accidents belong to such events. There is a line between these types of traumas and other stressful events of life such as illness or family problems. Usual skills of overcoming stress, which the majority of people have, as a rule, do not help to cope with traumatic experiences connected with PTSD.

The symptoms of PTSD have a pronounced and complex character. They include excessive fear, the feeling of helplessness, and horror, which can be expressed by children in their unusual behavior and disorganization. Children suffering from PTSD, show the symptoms in many respects similar to the symptoms of soldiers taking part in military operations and experiencing horrors of war. Children can have nightmares, fears, and panic attacks for many years. They can regress to previous stages of development and their behavior cannot correspond to age (for example, they can be afraid of strangers). Children with PTSD avoid situations that remind them of a traumatic event, or they can come back to this event. Often such children become pessimists, feel vulnerable, and can have problems at school.

Some characteristic symptoms are expressed differently among children and adults. For example, instead of repeating bright images that revive a traumatic event in the memory, the trauma is more often endured in nightmares. Nightmares reflect a traumatic event, but over time become nonspecific. Similar to it, the memories arising in the day time can be expressed in a game. Reaction to trauma among preschool children can be expressed in repeating drawings and games, the central theme of which is connected with trauma, regressive behavior, antisocial, aggressive, or destructive behavior.

The emergence of PTSD can be caused by both: a single stressful event and multiple mental traumas in early childhood. In certain cases, parents of children who experienced extraordinary stress are also exposed to traumatization and are inclined to denial or replacement of the fact of a trauma. Therefore, they are not reliable sources of information.

Acts of violence performed by people from a group of primary support of a child are especially dangerous, e.g. women associate themselves with the image of a mother, medical staff, teachers, and tutors. Early mental traumas are not usually revealed with their replacement and dissociation, however, the consequences of physical, psychological, and sexual trauma can be extremely serious and lead to the development of early PTSD in children.

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PTSD Statistics

For the first time, PTSD was described in the USA based on longitudinal studies of the mental condition of American soldiers, who returned from the war in Vietnam. In 1980, the concept of “post-traumatic stress disorder” (PTSD) was accepted as a distinct and reasonable diagnostic category. Post-traumatic stress disorder can be defined as a condition, developed by a person, who experienced psychological and emotional stress, which could be traumatic practically for any person.

The war in Afghanistan is very similar to the war in Vietnam in terms of the impact it had on people’s mental health. According to the National Research of Vietnam Veterans in 1988, about 30.6% of Americans participating in the war developed a full-scale PTSD; 22.5% developed partial PTSD. About 55.8% of people having PTSD also experienced psychological frustrations related to the probability of being jobless (in comparison with others), divorces (70%), parental problems (35%), extreme forms of isolation from people (47,3%), expressed hostility (40%), violence (36.8%), and arrest or imprisonment (50%) (Foa, 2009).

In modern terminology, PTSD is a chronic mental disorder caused by a psychologically stressful event occurring out of the range of normal human experience. About 8% of all population is subject to it, and women are twice as likely to develop PTSD in comparison to men. According to medical statistics, a big number of women who were victims of sexual violence or its attempt to have a similar disorder in the anamnesis. Any event, which caused strong stress, whether it was a physical abuse or casually seen murder, earthquake, or a fire, can be a reason of PTSD.

Both participants and involuntary witnesses of any military operations suffer from it. Different types of therapy directed mainly at noradrenergic, serotoninergic, and dopaminergic receptor complexes are most widely applied in the treatment of PTSD. Preclinical research convincingly confirms the key role of the noradrenergic system in concentration on bright and menacing events.

Some researchers believe that this system is especially important in the development of a group of symptoms of overexcitement associated with PTSD. During PTSD the binding of paroxetine by thrombocytes is broken. It depends on the expressiveness of the symptoms of PTSD and is an objective marker of the therapeutic forecast in treatment by selective inhibitors of the return capture of serotonin.

PTSD is not a frequent phenomenon. About 1% of the population suffers from PTSD, and separate symptoms of PTSD can appear in 15% of the population after heavy traumas such as a physical attack or military operations. PTSD becomes chronic in a considerable number of people. In the general population, the disorder is often combined with other mental illnesses, including affective frustrations and abuse of alcohol or other drugs.

If to consider only war participants, PTSD, which is a syndrome delayed in time from a stay in a traumatic situation of specific reactions with stratification of secondary stresses, is noted in 18.6% of almost healthy veterans of the war in Afghanistan; in 41.7% of chronically sick; in 56.2% of disabled people. The obtained representative data on the prevalence of PTSD among soldiers-internationalists testify that the signs of PTSD (various degree of expressiveness) occur in 62.3% of the surveyed.

Treatment of PTSD

According to Cloitre (2009), the treatment of posttraumatic stresses and disorders is a combination of the acquired experience directed at the adaptation of the standards of behavior and the relations that encourage and support an optimum level of health of a patient. Treatment is the process of implementing planned consecutive programs based on the checked principles of training and the theory of change of behavior.

Treatment of patients, who suffer from PTSD is a multilevel process of the adaptable activity of a human body. It is accompanied by the tension of mechanisms of self-control and fixing specific adaptive psychophysiological changes. Therapists should take into consideration that the process of treatment of patients suffering from PTSD is an adaptation to the situation of psychological stress as a complex of reactions directed at the adaptation to new conditions accompanied by such cardinal changes of mentality and identity of a patient. It is impossible to treat patients who suffer from PTSD without the elements of a change or behavior replacement, even in the presence of regulating law protecting the safety of people (Cloitre, 2009).

Therapists should take into consideration that the process of treatment of patients experiencing PTSD is an adaptation to the situation of psychological stress as a complex of reactions directed at the adaptation to unusual incentives of stressful conditions accompanied by such cardinal changes of mentality and identity of a patient.

Cognitive Processing Therapy (CPT)

Cognitive Processing Psychotherapy (CPT) or cognitive behavioral therapy is a general concept describing psychotherapy of psychological disorders (phobias, depressions, PTSD, etc.) and dysfunctional beliefs. There are five goals of CPT: 1) reduction and/or full elimination of the symptoms of PTSD; 2) decrease of the probability of recurrence emergence after the completion of treatment; 3) increase of the efficiency of pharmacotherapy; 4) solution of psychosocial problems (which can be a consequence of a mental disorder or precede its emergence); 5) elimination of the causes promoting the development of psychopathology: the change of dysadaptive beliefs (schemes), correction of cognitive mistakes, change of dysfunctional behavior.

CPT is a method of PTSD treatment, which is mainly concentrated on the thoughts and beliefs of a patient and also on behavioral models, which they cause. These models can influence a human's ability to perceive reality objectively and, therefore, they often lead to stresses. During cognitive therapy, a therapist together with a patient identifies similar models of thinking, analyzes them, and offers other alternative opportunities, which are more real and positive.

Contemporary research in the field of psychotherapy implemented by both the World Health Organization and the US Ministry of Health shows that the CPT is the most effective method of treatment of the majority of mental disorders such as disturbing frustration, abuses, persistence, PTSD, phobias, sexual frustration, etc. It also yields significant results in such areas as the treatment of neurosis, depression, and panic attacks. In western psychotherapy (CPT) is the most widespread method of treatment, showing good results in rather short terms.

CPT helps learn to think and react in a different way to frightening events that cause the development of PTSD and can help take illness symptoms under control. There are some types of CPT including:

“A colliding method” uses mental images, records, or visit of a place of the endured trauma to help victims face fear suppressed in them and take it under control.

“Cognitive restructuring” induces patients, who experienced a traumatic event to introduce depressing (often wrong) ideas of the trauma to challenge these thoughts and to replace them with more balanced and suitable ones.

“Introduction to a stressful situation” teaches the ways of reducing anxiety and increases patients' ability to cope with it, helps weaken PTSD symptoms, and correct the wrong train of thought connected with the endured trauma. The frequency of PTSD in the general population is high. Taking into consideration the fact that in the absence of adequate treatment PTSD becomes chronic, and also a high frequency of traumatic events usually precede it, it is possible to speak about the growth of the number of people suffering from PTSD.

Therefore, it is necessary to provide victims with treatment in due time, especially those with a high risk of developing a chronic form of a disease, and, along with it, to develop effective and economic methods of its treatment. CPT forms a reliable basis for the development of the CPT program. The study of fear connected with notions of compulsion and images of traumatic contents demands the initial activation of this emotional reaction.

“Hot” cognitive processes can be recovered in a session with the help of “induction in the imagination”. This procedure assumes the revival of distinct memories of the initial trauma. Along with it, negative thoughts, feelings or sounds, visions, smells, feelings of shame, fault, horror, are quickened and investigated.

“Cognitive restructuring” - the belief that nobody can be trusted and the world is unpredictable and dangerous can be the result of an intensive trauma and victimization. These “hot cognitive products” come to light during the mentioning of trauma or by means of the direct question asked for the clarification of what the traumatic event meant to the patient. Then a therapist helps the patient to change a negative belief, revealing cognitive distortions and confronting a destructive sense of these negative beliefs.

Cognitive processing therapy (CPT) belongs to the most studied types of psychosocial treatment of PTSD. They include a set of treatment methods that are different types of procedure of immersion, cognitive restructuring, and anxiety management techniques. According to intensive research, CPT is most often recommended as a psychosocial approach to PTSD treatment. The results of clinical researches show that the therapeutic effect lasts for several following years.

Prolonged Exposure Therapy

Prolonged Exposure Therapy (PET) is one of the components of CPT. Direct, courageous opposition to trauma is fulfilled using the so-called “exposition”. A patient imagines an event, speaks about it, and is gradually exposed to the influence of various signals, which remind him of a trauma. This procedure is repeated several times in a safe situation and under the supervision of a therapist.

According to Resick (2002), Prolonged Exposure Therapy (PET) is a technique of ensuring access to internal resources of a person necessary for adaptive permission of psychological problems and/or elimination of painful symptoms. Its major component is “flooding”, which relies on a flexible indirect model of the hypnotic trance based on cooperation and multilevel interpersonal interaction of a therapist and a patient. The method has a strategic character. A psychotherapist defines the main problems of a patient, plans the purposes of psychotherapy, and offers certain approaches for their achievement. It is short-term and, first of all, is aimed at the restoration of the emotional and physical health of people, suffering from PTSD.

At first, this method of treatment causes the strongest emotions, but at a certain stage, a patient “gets used” to thoughts of trauma. At this stage, traumatic experiences, which were so awful at the beginning of treatment become usual memories from the past. The difference between PET and constant heavy memories, which are characteristic of PTSD, lies at a control level. In the first case, painful memories are initiated by the patient. Thus, the ability of management eliminates helplessness before their memory.

EMDR Therapy

EMDR (Eye Movement Desensitization and Reprocessing) is a method of psychotherapy developed by Francine Shapiro for the therapy of post-traumatic stress disorder (PTSD) caused by experiences such as violence or participation in military actions. According to Shapiro’s theory, when a person experiences trauma or distress, this experience can “block” the possibilities of ordinary cognitive and neurologic mechanisms to cope with the stress associated with an event. Thus memories are processed inadequately and dysfunctionally and remain in isolated memory chains. The purpose of EMDR therapy is to process these distressing memories to reduce their detaining influence and allow the client to develop more adaptive mechanisms of coping (Shapiro, 2001).

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EMDR integrates the elements of psychodynamic and exposition approaches, cognitive, interpersonal, experimental, and corporal-focused psychotherapies. However, it contains a unique element of bilateral stimulation (movement of eyes, sound and tactile stimulation) in each session. EMDR uses the structured eight-phase approach related to previous, current. and future aspects of traumatic experience and dysfunctionally stored stressful memoirs. During a phase of EMDR processing, a client is focused on the disturbing memories during short sets consisting of 15-30 seconds. Thus, at the same time, the client is focused on the alternative stimulation (for example, eye movements directed by the therapist, hands claps or bilateral acoustical incentives) (Davidson, 2001).

Phases of EMDR treatment include:

  1. Patient’s story and treatment plan (goals).
  2. “A safe place” - a comfortable place or a positive image of a patient.
  3. Determination of “a negative cognition” and “a positive cognition”.
  4. A set of eye movements (a phase of desensitization).
  5. “Installation phase”.
  6. Body scanning - a set of bilateral stimulation.
  7. Debriefing - necessary information and support.
  8. Overestimation - a level of anxiety is estimated.

Bradley (2005) says "results suggest that psychotherapy for PTSD leads to a large initial improvement from baseline. More than half of patients who complete treatment with various forms of cognitive behavior therapy or eye movement desensitization and reprocessing improve".

The latest research estimates EMDR as an effective method of PTSD treatment. The practice guidelines of the International Society for Traumatic Stress Studies categorize EMDR as a reliable method of PTSD among adults. A meta-analysis of 38 randomly-controlled types of research of PTSD treatment conducted by Bisson in 2007 recommends CPT and EMDR as the main ways of PTSD treatment.


People with PTSD show anxiety and the symptoms caused by the traumatic event. The symptoms of PTSD are shown soon after trauma and last less than a month. The symptoms of PTSD can begin at any time (even in years) after trauma and last for months or years. The techniques and therapies aimed to treat PTSD include CPT, EMDR, and PET. Clinical physicians can also use insight-therapy, family therapy, and group therapy (including debatable groups for veterans of military operations) to help victims come to an understanding of an event and see prospects.

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