Posttraumatic Stress Disorder 493
program and various alcohol rehabilitation initiatives. CBT targeted various
automatic thoughts and beliefs related to trauma, PTSD symptoms and depres-
sion, but also included other treatment components such as trauma exposure,
applied relaxation, graded exposure, and behavioral activation.In the remainder of this chapter we will refer back to Edward in order to illustrate
the cognitive basis of PTSD and its treatment. But first we begin with a brief consider-
ation of diagnostic issues in PTSD, as well as the nature of trauma and predictors of risk
and resiliency. This will be followed by a description of the cognitive model of PTSD
and its empirical status. The remainder of the chapter discusses cognitive assessment,
case formulation, treatment, and its efficacy.
DiagnostiC ConsiDerationsDSM-IV Diagnostic Criteria
PTSD was first introduced as an official diagnostic construct in DSM-III (American
Psychiatric Association [APA], 1980). It is the only anxiety disorder to include an etio-
logic variable in its diagnostic criteria, that is, PTSD is defined as a person’s response
to a specific event (McNally, 2003a). To meet diagnostic criteria for PTSD (Criterion
A1), DSM-IV requires exposure to an extreme traumatic stressor involving (1) actual
or threatened death or serious injury to self or threat to one’s physical integrity; (2) wit-
nessing death, serious injury, or threat to the physical integrity of another person; or (c)
learning about unexpected death, serious harm, or threat of death or injury to a family
member or close friend (APA, 2000). In addition the person’s response to the event must
involve intense fear, helplessness, or horror (Criterion A2). PTSD, then, can occur in
response to a wide range of traumatic events such as war, rape, torture, crime, motor
vehicle accidents, industrial accidents, natural disasters, incarceration as a prisoner of
war or in a concentration camp, sudden death of a loved one, being diagnosed with a
life- threatening illness, and the like (APA, 2000; Keane & Barlow, 2002). Table 12.1
presents the DSM-IV-TR diagnostic criteria for PTSD.
Three other symptom categories must be present in response to the traumatic stres-
sor in order to meet diagnostic criteria for PTSD. Resick, Monson, and Rizvi (2008)
made a number of observations about these symptom categories. At least one reexperi-
encing symptom must be present which represents some form of intrusive recollection
or reminder of the trauma that is associated with strong negative affect and is experi-
enced in an uncontrollable fashion. The avoidance and numbing symptoms (Criterion
C) may reflect the individual’s attempt to gain psychological distance from the trauma
and reduce the negative emotions associated with the reexperiencing symptoms. The
physiological hyperarousal symptoms (Criterion D) reflect the individual’s persistent
state of hypervigilance for new threats or dangers but ultimately this will have a det-
rimental effect on daily functioning. A 1-month duration criterion is included because
the majority of individuals (i.e., over 90%) experience symptoms consistent with PTSD
immediately after a trauma but these symptoms remit for most individuals by 3 to 6
months (Monson & Friedman, 2006). DSM-IV also introduced a clinically significant
distress or functional impairment criterion to PTSD, which along with the addition of