Posttraumatic Stress Disorder 553
control strategies such as thought suppression, rumination, avoidance, and safety seek-
ing to extinguish reexperiencing symptoms and negative affect. Although these mal-
adaptive coping responses may lead to an immediate sense of relief, in the long term
they contribute to the persistence of the disorder by contributing to the activation of
maladaptive trauma- related schemas and associated trauma- related intrusive thoughts,
images, and recollections.
There was fairly consistent research support that PTSD is characterized by (1) mal-
adaptive, biased encoding of the trauma experience; (2) greater endorsement of negative
beliefs about threat, vulnerability, and danger for self, world, future, and other people;
(3) a strategic but not preconscious attentional bias for threat; (4) enhanced explicit
recall of trauma- related information as well as a more fragmented, poorly elaborated
trauma memory; (5) an explicit negative appraisal of trauma, its consequences, and the
impact of reexperiencing symptoms; (6) reliance on cognitive avoidant coping strategies
like thought suppression to quell unwanted intrusive thoughts, images, or memories of
trauma; and (7) presence of avoidance and safety- seeking behaviors. However, a num-
ber of issues remain for further investigation. Much of the support for a cognitive basis
to PTSD was found at the elaborative phase, with less evidence of a bias in preconscious
automatic processes. Most of the research on negative beliefs, appraisals, and coping
strategies relied on retrospective self- report questionnaires. More experimental studies
utilizing “online” assessment of appraisals are clearly needed. Further research is also
needed to determine whether the threat bias in PTSD is due to facilitated processing
of threat, difficulty with threat disengagement, and/or failure to process safety cues.
Finally, more prospective research is needed to determine the mediational role of these
cognitive variables in the persistence of PTSD.
The objectives of cognitive therapy for PTSD are (1) to improve memory of the
trauma so it can be integrated with other autobiographical memories; (2) deactivate
hypervalent schemas of threat, danger, and vulnerability; (3) increase acceptance of the
intrusive thoughts, images, and memories of trauma; (4) eliminate maladaptive cogni-
tive strategies like thought suppression and rumination; and (5) reduce avoidance of
PTSD or anxiety- eliciting situations and reliance on safety- seeking cues. These goals
are accomplished by psychoeducation into the cognitive model, cognitive restructur-
ing of negative appraisals and beliefs about the trauma and its consequences as well
as the adverse effects of PTSD, in vivo exposure to avoided situations, modification
of dysfunctional cognitive control strategies (e.g., thought suppression), and repeated
imaginal exposure to the trauma memory. A number of randomized control trials have
shown that cognitive therapy or CBT has immediate and enduring efficacy in the treat-
ment of PTSD. As a result CBT is now recognized as a first-line choice of treatment
for the disorder and can be considered an empirically supported treatment for PTSD.
Although many fundamental issues are unresolved about the etiology, maintenance,
and treatment of PTSD, tremendous progress has been made since the disorder was first
introduced into the diagnostic nomenclature in 1980.