516 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Search for Safety and Avoidance
Avoidance is so pervasive in PTSD that it is included as an important diagnostic crite-
rion. Behavioral (i.e., avoiding people, places, or other cues that are reminders of the
trauma), cognitive (i.e., avoiding thinking about aspects of the trauma), and experiential
(i.e., avoiding negative emotions associated with the trauma) avoidance are included in
Criterion C. As in the other anxiety disorders, avoidance is a maladaptive strategy that
prevents disconfirmation of the dysfunctional beliefs and appraisals of current threat. In
this way avoidance will contribute to the persistence of PTSD. In addition, other behav-
iors may be initiated in order to provide a sense of safety. Edward, for example, avoided
large crowds because they reminded him of the throngs of hungry and frightened Rwan-
dans in overcrowded refugee camps. Moreover, hypervigilance in public places was a
safety behavior he used to anticipate any cue that might remind him of Rwanda. Despite
his reliance on avoidance and safety behaviors, the person with PTSD rarely achieves
the “sense of safety” that he so desperately seeks.
Clinician Guideline 12.13
Deliberate attempts to manage the unwanted reexperiencing symptoms and hyperarousal
of PTSD significantly contribute to a persistence of the disorder. Threat misinterpretations
of trauma- related intrusions, ineffective thought control efforts, emotional and behavioral
avoidance, and reliance on safety- seeking responses each contribute to the persistence of a
negative emotional state and the disorder itself. Modification or replacement of these mal-
adaptive response strategies is an important component of cognitive therapy for PTSD.Persistence of Distress
The end result of the maladaptive automatic and elaborative posttrauma processes
described in the cognitive model is the persistence of a negative emotional state. It is well
known that anxiety is not the only negative emotion experienced in PTSD. Individuals
also experience other strong emotions such as shame, guilt, anger, and sadness (Resick,
Monson, & Rizvi, 2008). From the cognitive perspective, a more generalized negative
emotional state is expected given the broad range of dysfunctional schemas involved in
PTSD such as threat to safety and well-being, heightened personal vulnerability, and
negative worldview. As noted in Figure 12.1 the relationship between faulty informa-
tion processing and negative emotional state is bidirectional, with a persistent negative
affective state feeding back to ensure the continued activation of the PTSD schematic
constellation.
empiriCal status of the Cognitive moDelIn this section we review the empirical support for the cognitive model of PTSD. Seven
hypotheses are proposed that are critical to the cognitive model, although this does not
preclude other predictions that can be derived from the model. However, we consider
these seven hypotheses most important for evaluating the empirical status of the model.