CBT for post-traumatic stress disorder
State-of-the-art CBT for post-traumatic stress disorder (PTSD) typically has three objectives:
• To help the person to stop reliving the trauma by addressing their incomplete and chaotic memory of the event.
• To change the negative views the person holds about the trauma and what it means for them.
• To help the person to no longer avoid reminders of the trauma, or to numb their feelings with alcohol or drugs.
Treatment normally involves ten to twelve weekly ninety-minute sessions, followed by three monthly ‘booster’ sessions. This requires a very significant commitment of time (and emotion) on the part of the client. But a team of renowned CBT developers – Nick Grey, Freda McManus, Ann Hackmann, David Clark, and Anke Ehlers – has piloted an intensive course of treatment for PTSD, with sessions concentrated into one week. Let’s look at an example from them.
Mark, a 31-year-old professional, had been suffering from nightmares, flashbacks, anger, and depression following a motorbike accident nine months previously. He felt so distressed and low that he contemplated suicide every day.
During the first part of the week, Mark was encouraged to ‘relive’ the accident in his imagination. His most upsetting memories were of sliding down the road after being hit by a car; the looming bus which he had believed would run him over; and lying in the road after the accident. Accompanying these memories were some very negative thoughts. He believed, for example, that his life was ‘full of crap’, and that the image of him lying alone on the ground epitomized his general isolation.
As the sessions progressed, Mark was helped both to fill in the gaps in his memory of the trauma and to challenge his negative thoughts. He remembered, for example, that several passers-by had been helpful and attentive, and that he’d lain alone in the road for much less time than he’d previously believed. Through discussions with the therapist, Mark came to see that his life was far from as bleak as he sometimes felt it was, and that he wasn’t alone.
Mark was also encouraged to revisit the site of the accident – something he had always avoided. He began to ride his motorbike again. And for the first time, he was able to discuss his experience with his girlfriend.
A week after therapy, Mark’s symptoms were greatly improved. And the gains lasted: 18 months later, Mark was still well and enjoying life.
Virtual-reality CBT
The exposure element within CBT works, but it’s not without its drawbacks. It’s suspected, for example, that some people are so reluctant to experience the situation they fear that they don’t seek treatment. And how does one easily create exposure situations for someone who is afraid of flying?
One solution is virtual-reality (VR) CBT. This involves the individual wearing a specially designed headset that immerses them in a computer-generated representation of whatever it is they fear, complete with sounds, and sometimes even smells. VR has been used to treat panic disorder, social phobia, and fears of flying, spiders, and heights with similar success to normal ‘in vivo’ exposure therapy. VR CBT is now being tested as a possible therapy for US veterans suffering from PTSD following service in Iraq and Afghanistan.
Self-help CBT
As a look around any decent-sized bookshop will tell you, self-help is big business. But does ‘self-help’ – and specifically CBT-based material – really help?
Before we answer that question, it’s worth pointing out that these days self-help comes in several varieties. There are the traditional books – offering what’s known as bibliotherapy; CD-ROMs; audio tapes; and Internet-based resources.
There’s certainly no disputing the demand: many self-help books have gone on to become bestsellers, and the US National Institute of Mental Health reports seven million hits on its website every month. For many people, self-help is a much more palatable method of tackling their psychological problems than seeking advice from a health professional. And those same health professionals often recommend that their patients consult self-help materials as part of their treatment.
Which brings us back to that key question: does CBT-based self-help work? The evidence suggests that it can do, at least to some extent. But it tends to be much more effective when there’s also input from a therapist in person.
Lifestyle
If you’re concerned about your anxiety levels, a few changes to your lifestyle may well improve your mood a lot over time.
Well-controlled studies in this area are not plentiful, but there is evidence to suggest that anxiety can be lessened by:
• aerobic exercise;
• healthy diet;
• relaxation training (in which you learn to progressively relax your muscles);
• massage;
• yoga;
• mindfulness (a synthesis of modern Western psychological thinking and ancient Buddhist beliefs and practices, particularly meditation, that emphasizes learning to live in the moment, and understanding that your thoughts and feelings are temporary, transient, and not necessarily a reflection of reality).
A telling illustration of the difference the first two on this list can make was provided by a two-year study of more than 10,000 people living in some of the poorest areas of Britain. Large increases in the amount of physical exercise taken or the quantity of fruit and vegetables eaten led to significant improvements in mental health. In particular, people reported feeling much more peaceful and happy.
Anxiety can cause major difficulties for many people. But, as we’ve seen, there are now many ways of dealing with problematic anxiety. Some have been recognized for centuries; some were discovered by chance; and some of the most promising are based on the research into the causes of anxiety we’ve described in this book.
Appendix
Self-assessment questionnaires and further information
This Appendix contains self-assessment questionnaires for:
• social phobia
• generalized anxiety disorder (GAD)
• obsessive-compulsive disorder (OCD)
• post-traumatic stress disorder (PTSD)
It’s important to bear in mind that these questionnaires won’t provide a cast-iron diagnosis – for that, you’d need to see a specialist. However, they will give you an indication as to whether it may be useful to seek professional advice. For more information on treatment options, see Chapter 11.
In the Further reading section, you’ll find a list of books and websites providing more information on each of the six main psychological disorders.
Social phobia
When you complete the following questionnaire, base your answers on your experiences over the past week.
A total score of 19 or more is a sign of possible social phobia.
Social Phobia Inventory © 2000 Royal College of Psychiatrists
Generalized anxiety disorder
If you’re concerned that your worrying might be getting out of control, try the Penn State Worry Questionnaire.
For each of the following statements, indicate how typical or characteristic they are for you by giving a score from 1 to 5.
Penn State Worry Questionnaire: Meyer, T. J., Miller, M. L., Metzger, R. L., and Borkovec, T. D., (1990). Development and validation of the Penn State Worry Questionnaire, Behaviour Research and Therapy, 28: 487–95.
Now add up your scores for each statement. Questions 3, 8, 10, and 11 are reversed scored: if, for example, you put 5, for scoring purposes the item is counted as 1. Scores can range from 18 to 80.
People with worry problems usually score above 50. A score of over 60 may indicate GAD.
Obsessive-compulsive disorder
When you answer the following questions, think back to your experiences over the past month.
Questionnaire reproduced by permission of Edna B. Foa 2002.
Add up your score. A total of 21 or above indicates possible OCD.
Post-traumatic stress disorder
For this questionnaire, pl
ease base your responses on your reaction over the past seven days to the traumatic event.
As we saw in Chapter 10, there are three main types of PTSD symptom:
• Reliving the traumatic event is measured by items 1, 2, 3, 6, 9, 14, 16, 20. Scores can range from 0 to 32.
• Avoidance or feeling numb is measured by items 5, 7, 8, 11, 12, 13, 17, 22. Again, scores can range from 0 to 32.
• Feeling constantly on edge is measured by items 4, 10, 15, 18, 19, 21. Scores can range from 0 to 24.
The higher the scores, the more likely it is that you may be suffering from PTSD. Some experts estimate a total score of 30 or higher for the whole questionnaire indicates possible PTSD, but, as with all the questionnaires in this Appendix, a diagnosis can only be made by a clinician after a detailed assessment.
Impact of Event Scale – Revised © Weiss, D. S., and Marmar, C. R. (1997).
Appendix acknowledgements
Social phobia questionnaire reproduced from Connor, K., Davidson, J., Churchill L., Sherwood, A., Weisler, R., & Foa, E., ‘Psychometric properties of the Social Phobia Inventory’. British Journal of Psychiatry (2000), 176, 379–386 with permission from The Royal College of Psychiatrists © 2000 The Royal College of Psychiatrists.
Generalized anxiety disorder questionnaire reproduced from Meyer, T.J., Metzger, R.L. & Borkovec, T.D., ‘Development and validation of the Penn State Worry Questionnaire’. Behaviour Research and Therapy (1990), 28, 487–495 with permission from © Elsevier.
Obsessive-compulsive disorder questionnaire reproduced with permission from Professor Edna B. Foa (2002).
Post-traumatic stress disorder questionnaire reproduced from Weiss, D.S. & Marmar, C.R., ‘The Impact of Event Scale – Revised’ in Wilson, J. & Keane, T.M. (eds) Assessing Psychological Trauma and PTSD (1997) pp. 399–411, New York: Guilford with permission from Professors Daniel S. Weiss and Charles Marmar.
Sources
Chapter 1
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. (Arlington, VA: American Psychiatric Association).
Arrindell, W.A., Emmelkamp, P.M.G. and Van der Ende, J. (1984). Phobic Dimensions—I. Reliability and Generalizability across Samples, Gender and Nations. Advances in Behaviour Research and Therapy, 6: 207–254.
Banse, R. and Scherer, K.R. (1996). Acoustic Profiles in Vocal Emotion Expression. Journal of Personality and Social Psychology, 70: 614–636.
Barlow, D.H. (2002). Anxiety and its Disorders, 2nd edn. (New York: Guilford Press).
Berrios, G. & Porter, R. (eds.) (1995). A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders. (London: Athlone Press).
Dalgleish, T. and Power, M. (1999). Handbook of Cognition and Emotion. (Chichester: Wiley).
Darwin, C. (1872/1999). The Expression of the Emotions in Man and Animals. (London: Fontana).
Edelmann, R.J. (1992). Anxiety. (Chichester: Wiley).
Ekman, P. (1992). An Argument for Basic Emotions. Cognition and Emotion, 6, 169–200.
Hertenstein, M., Keltner, D., App, B., Bulleit, B.A., and Jaskolka, A.R. (2006). Touch Communicates Distinct Emotions. Emotion, 6: 528–533.
Kessler, R.C., Chiu, W.T., Demler, O. and Walters, E.E. (2005). Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62: 617–627.
Lewis, A. (1970). The Ambiguous Word ‘Anxiety’. International Journal of Psychiatry, 9: 62–79.
Oatley, K., Keltner, D., and Jenkins, J.M. (2006). Understanding Emotions, 2nd edn. (Oxford: Blackwell).
Power, M. and Dalgleish, T. (1997). Cognition and Emotion: From Order to Disorder. (Hove: Psychology Press).
Rachman, S. (2004). Anxiety, 2nd edn. (Hove and New York: Psychology Press).
Susskind, J.M., Lee, D.H., Cusi, A., Feiman, R., Grabski, W. and Anderson, A.K. (2008). Expressing Fear Enhances Sensory Acquisition. Nature Neuroscience, 11: 843–850.
Tuma, A.H. and Maser, J.D. (eds) (1985). Anxiety and the Anxiety Disorders. (New Jersey: Lawrence Erlbaum Associates).
Chapter 2
Barlow, D.H. (2002). Anxiety and its Disorders, 2nd edn. (New York: Guilford Press).
Barlow, D.H. and Durand, V.M. (2005). Abnormal Psychology: An Integrative Approach. (Belmont, CA: Thomson Wadsworth).
Beck, A.T. and Emery, G. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective. (Cambridge, MA.: Basic Books).
Bishop, S.J. (2007). Neurocognitive Mechanisms of Anxiety: An Integrative Approach. Trends in Cognitive Sciences, 11: 307–316.
Britton, J.C. and Rauch, S.L. (2009). Neuroanatomy and Neuroimaging of Anxiety Disorders. In M.M. Antony and M.B. Stein (eds.), Oxford Handbook of Anxiety and Related Disorders. (New York: Oxford University Press).
Cannistraro, P.A. and Rauch, S.L. (2003). Neural Circuitry of Anxiety: Evidence from Structural and Functional Neuroimaging Studies. Psychopharmacology Bulletin, 37: 8–25.
Charney, D.C. and Nestler, E.J. (2004). Neurobiology of Mental Illness, 2nd edn. (New York: Oxford University Press).
Clark, D.A. and Beck, A.T. (2010). Cognitive Therapy of Anxiety Disorders. (New York: Guilford).
Clark, D.M. (1999). Anxiety Disorders: Why They Persist and How to Treat Them. Behaviour Research and Therapy, 37: S5-27.
Damasio, A.R., Grabowski, T.J., Bechara, A., Damasio, H., Ponto, L.L.B., Parvizi, J., and Hichwa, R.D. (2000). Subcortical and Cortical Brain Activity during the Feeling of Self-generated Emotions. Nature Neuroscience, 3: 1049–1056.
Edelmann, R.J. (1992). Anxiety. (Chichester: Wiley).
Freud S. (1895/1979). On the Grounds for Detaching a Particular Syndrome from Neurasthenia under the Description ‘Anxiety Neurosis’, in On Psychopathology (London: Penguin).
Freud, S. (1933/1991). Anxiety and Instinctual Life, in New Introductory Lectures on Psychoanalysis, vol. 2. (London: Penguin).
Gray, J.A. and McNaughton, N. (2000). The Neuropsychology of Anxiety, 2nd edn. (Oxford: Oxford University Press).
Holmes, E.A. and Mathews, A. (2005). Mental Imagery and Emotion: A Special Relationship? Emotion, 5: 489–497.
LeDoux, J. (1998). The Emotional Brain. (New York: Phoenix).
Mathews, A., Richards, A., and Eysenck, M. (1989). Interpretation of Homophones Related to Threat in Anxiety States. Journal of Abnormal Psychology, 98: 31–34.
Mowrer, O.H. (1939). A Stimulus-Response Analysis of Anxiety and Its Role as a Reinforcing Agent. Psychological Review, 46: 553–565.
Oatley, K., Keltner, D., and Jenkins, J.M. (2006). Understanding Emotions, 2nd edn. (Oxford: Blackwell).
Rachman, S. (2004). Anxiety, 2nd edn. (Hove and New York: Psychology Press).
Rose, S. (2011). Self Comes to Mind: Constructing the Conscious Brain by Antonio Damasio. The Guardian, 12 February 2011.
Salkovskis, P. (ed.) (1996). The Frontiers of Cognitive Therapy. (New York: Guilford).
Sheehy, N. (2004). Fifty Key Thinkers in Psychology. (London and New York: Routledge).
Watson, J. and Raynor, R. (1920). Conditioned Emotional Reactions. Journal of Genetic Psychology, 37: 394–419.
Chapter 3
Barlow, D.H. (2002). Anxiety and its Disorders, 2nd edn. (New York: Guilford Press).
Barlow, D.H. and Durand, V.M. (2005). Abnormal Psychology: An Integrative Approach. (Belmont, CA: Thomson Wadsworth).
Caspi, A. and Moffitt, T.E. (2006). Gene–Environment Interactions in Psychiatry: Joining Forces with Neuroscience. Nature Reviews Neuroscience, 7: 583–590.
Clark, D.A. and Beck, A.T. (2010). Cognitive Therapy of Anxiety Disorders. (New York: Guilford).
Eley, T.C., Gregory, A.M., Lau, J.Y.F., McGuffin, P., Napolitano, M., Rijsdijk, F., and Clark, D.M. (2008). In the Face of Uncertainty: A Twin Study of Ambiguous Information, Anxiety and Depression in Children. Journal of Abnormal Child Psychology, 36: 55–65.
Eley, T.C., Gregory, A.M., Clark, D.M., a
nd Ehlers, A. (2007). Feeling Anxious: A Twin Study of Panic/Somatic Ratings, Anxiety Sensitivity and Heartbeat Perception in Children. Journal of Child Psychology and Psychiatry 48: 1184–1191.
Gerull, F.C. and Rappe, R.M. (2002). Mother Knows Best: Effects of Maternal Modeling on the Acquisition of Fear and Avoidance Behavior in Toddlers. Behaviour Research and Therapy, 40: 279–287.
Gelernter, J. and Stein, M.B. (2009). Heritability and Genetics of Anxiety Disorders. In M.M. Antony and M.B. Stein (eds.), Oxford Handbook of Anxiety and Related Disorders. (New York: Oxford University Press).
Anxiety Page 13