546 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Disorder- Focused Cognitive Restructuring
As noted earlier in this chapter, many of the symptoms of PTSD are common reac-
tions in the immediate aftermath of trauma. However, if these initial symptoms such
as intrusive recollections, flashbacks, nightmares, anger, poor concentration, anxiety,
numbing, and the like are interpreted negatively as signs of weakness, sickness, mental
disturbance, loss of control, and so on. rather than a normal part of the recovery pro-
cess, these appraisals can contribute to the persistence of the symptoms (Ehlers & Clark,
2000). Taylor (2006) noted that disorder- focused negative appraisals and beliefs fall
under three categories: (1) beliefs about specific PTSD symptoms (e.g., “Having frequent
flashbacks means that the PTSD is getting worse”), (2) beliefs about arousal- related
symptoms (e.g., “If my chest tightens too much and I become short of breath, I might
faint”), and (3) beliefs about general psychological functioning (e.g., “PTSD has robbed
me of a meaningful life”, “I will never achieve anything because PTSD has ruined my
memory or ability to concentrate”). We would add that the clients’ perceptions of how
other people evaluate and respond to them because of the trauma or suffering from
PTSD are another important type of disorder- related thinking targeted in treatment.
Cognitive restructuring, empirical hypothesis testing, generating alternative inter-
pretations, and mindful detachment/acceptance will be the primary interventions for
modifying disorder- focused appraisals and beliefs. Work on these beliefs will occur
throughout the course of cognitive therapy and may become particularly evident when
conducting imaginal or in vivo exposure sessions. Once a disorder- specific belief is iden-
tified, the therapist should focus on modifying that belief before continuing further with
exposure or trauma memory reconstruction. If left unchecked, the disorder- specific neg-
ative beliefs will interfere in treatment progress. The following evaluation forms may be
assigned Testing Anxious Appraisals: Looking for Evidence (Appendix 6.2), Empirical
Hypothesis- Testing Form (Appendix 6.5), or Symptom Reappraisal Form (Appendix
8.2).
A number of disorder- related negative beliefs and appraisals were identified in the
course of Edward’s treatment. For example, he believed that the occurrence of sudden
intrusive images of “the little girl and gorilla in an RPA uniform” meant that his PTSD
was getting worse and that he could eventually “go crazy” if he did not stop the images.
Cognitive restructuring focused on gathering personal evidence that the unwanted
images really were associated with deterioration and testing out an alternative perspec-
tive where the images were viewed as an annoyance in which the best response was
benign acceptance and detached observation. Edward also believed that he could have
a heart attack if he experienced heart palpitations, tension, and trembling because of
heightened anxiety (he was receiving medical treatment for hypertension and elevated
cholesterol). Cognitive restructuring and in vivo exposure to anxiety- provoking situ-
ations were used to disconfirm Edward’s threat interpretations of anxious symptoms.
Edward also believed that he no longer had any personal value because of PTSD (i.e.,
mental defeat) and that he could no longer achieve anything worthwhile or attain any
degree of satisfaction in life. His life was one big disappointment because of PTSD. Cog-
nitive restructuring focused on (1) reassessing his personal value based on forgotten past
achievements, (2) correcting the overgeneralization error associated with the trauma
and its effects, (3) and developing a “management perspective” on PTSD (i.e., “PTSD is
like diabetes, people can live productive and fulfilling lives if it is managed properly”).