552 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Given that cognitive restructuring and exposure are the two primary components
of cognitive therapy for PTSD, a comparison of their relative contributions is an impor-
tant empirical question for understanding treatment effectiveness. Studies comparing
trauma- focused imaginal and situational exposure versus CBT (exposure plus cogni-
tive restructuring of trauma appraisals and beliefs) have found both treatments equally
effective in reducing PTSD severity (Foa, Hembree, et al., 2005; Foa & Rauch, 2004;
Marks et al., 1998; Paunovic & Öst, 2001). Some have questioned whether cognitive
restructuring is necessary since it does not appear to enhance the treatment effective-
ness of trauma exposure. However, in other studies cognitive therapy without system-
atic trauma exposure was equally effective to prolonged exposure (Marks et al., 1998;
Resick et al., 2002; Tarrier et al., 1999), and in one case imaginal exposure plus cogni-
tive restructuring was superior to imaginal exposure alone (Bryant, Moulds, Guthrie, et
al., 2003). We conclude from these studies that exposure and cognitive restructuring are
both effective therapeutic ingredients for treatment of PTSD but an incremental clinical
improvement from combining them has not yet been demonstrated.
Clinician Guideline 12.30
Cognitive restructuring of trauma- related appraisals and beliefs as well as systematic and
repeated trauma- focused in vivo and imaginal exposure are effective therapeutic ingredients
of cognitive therapy that produce significant and enduring reductions in PTSD symptoms,
generalized anxiety, and depression as well as improved daily functioning for chronic PTSD
caused by a wide range of traumas.summary anD ConClusionPTSD is an anxiety disorder that occurs in response to a traumatic stressor and con-
sists of trauma- related reexperiencing symptoms, avoidance or emotional numbing, and
increased physiological arousal. It has a swift onset, with the majority of cases occur-
ring within 1 month of a trauma, followed by a steep remission rate of 40–60% over a
6–12 month period.
Recognizing that only a minority of individuals exposed to trauma develop PTSD,
the cognitive theory presented in Figure 12.1 proposes a diathesis– stress perspective in
which certain enduring dysfunctional beliefs about personal vulnerability and danger
interact with particular features of a traumatic experience to elevate the probable onset
of PTSD. Once the threshold for onset is exceeded, cognitive processes at the auto-
matic and elaborative levels of information processing ensure the persistence of PTSD
symptoms. At the automatic level, the person with PTSD exhibits selective attentional
priority for any trauma- related threat or danger cues, has a poorly elaborated and frag-
mented autobiographical memory of the trauma, and selective recall of the past trauma
experience, which together reinforce negative beliefs about self, world, and future. At
the elaborative, or strategic, level of information processing, the person with PTSD
engages in deliberate threat appraisal of the trauma and its consequences, as well as the
deleterious effects of PTSD symptoms, and relies on various cognitive and behavioral