Prolonged exposure (PE) was developed to separate the traumatic memory from the conditioned emotional fear response so that the memory no longer dominates thoughts, feelings, and behavior. This approach uses both imaginal and in vivo exposure [15–19].

Imaginal exposure—systematically assisting trauma survivors to confront distressing trauma memories through the use of mental imagery.

In vivo exposure—patients practice techniques learned in therapy by exposing themselves to environmental stimuli that represent their most feared situations.

Clinicians ask patients receiving imaginal exposure to narrate the traumatic event. If numerous traumatic episodes exist (as with survivors of recurrent child abuse, domestic violence, war trauma, or torture), the clinician asks patients to construct narratives about the worst events they clearly remember. The clinician prompts patients to close their eyes and visualize (imagine) what happened while repeating the narrative several times during a single session. Initially, patients will experience great anxiety as they begin to imagine themselves back in the traumatic situation. They are asked to rate the level of subjective distress every 10 min on a 10–100 Subjective Units of Distress Scale (SUDS), where 10 is no distress and 100 is the most fear/helplessness/horror they have ever experienced. The SUDS scoring system allows the patient to express exactly how upsetting or distressing certain stimuli are in comparison to other anxiety experiences. Distress levels are usually in the 70–90 range during initial imaginal exposure sessions. However, through repeated exposure to the traumatic memory, patients experience a progressive reduction in distress levels so that they may fall to the 10–20 range by the end of a single session and remain at negligible levels by the end of an 8- to 10-session exposure therapy treatment. When ready, patients are encouraged, as part of a homework assignment, to confront situations associated with their traumatic experiences in the context of in vivo exposure [15–19]. Following successful exposure treatment, patients can confront traumatic memories without having the recollections trigger intrusion and/or arousal and reactivity PTSD symptoms.

The mechanism of action of PE is thought to be through extinction of negative emotions (fear, anxiety, sadness, guilt) associated with traumatic reminders. The protocol, by which patients are repeatedly exposed to their own individualized trauma stimuli until their SUDS levels have been persistently reduced, is directly comparable to psychological laboratory fear extinction paradigms following fear conditioning. As a result, it is possible to carry out laboratory research that has direct relevance to PE. For example, animal research with D–cycloserine (see below) raised the possibility that such an approach might have clinical benefit.

PE, CPT, and other trauma-focused treatments may not be for everyone; some patients are either not ready or not willing to confront traumatic reminders and the intense anxiety provoked by this technique.

Efficacy—PE has consistently proven superior to supportive counseling or untreated patients monitored while on a “waiting list” for therapy. It is equal in efficacy to other forms of CBT treatment; results have shown 60–70 % improvement in all three DSM-IV PTSD symptom clusters with improvements generally maintained 6 and 12 months later. In one important study, improvement from PE was sustained for 5 years [15, 16, 20–24].

Cognitive therapy addresses thoughts and beliefs generated by the traumatic event rather than conditioned emotional responses addressed by exposure therapy [19–28]. This approach focuses on how individuals with PTSD have interpreted the traumatic event with respect to their appraisals about the world and themselves. For example, those who have been overwhelmed by a catastrophic stressor typically perceive the world as dangerous and themselves as incompetent. As a result, PTSD patients see themselves as perennial victims powerless to cope with life and take charge of their personal destiny. Such a belief system then becomes a hard-wired, self-fulfilling prophecy.

In cognitive therapy, the first step is to identify dysfunctional automatic thoughts (such as Mary’s thoughts about herself) and to understand that, although originally developed from the trauma, these thoughts currently hinder adaptive functioning. Second, the therapy focuses on challenging and disputing these beliefs by examining evidence for or against them. Third, treatment focuses on correcting such erroneous thoughts with more accurate information or replacing automatic, dysfunctional thoughts with more realistic, evidence-based, and adaptive beliefs. Successful cognitive therapy creates an accurate appraisal of:

Efficacy—Several studies comparing cognitive therapy with PE (alone and in combination) found equal effectiveness, producing 60–70 % improvement in PTSD symptoms. Additionally, these individual or combined approaches outperformed relaxation therapy [16, 20, 22, 27, 28].

CPT also uses written narratives to address both the emotional and cognitive consequences of trauma exposure so that patients can access and process the natural emotions that have been distorted and obscured by their personal interpretations of the traumatic event [16, 29–31].

According to CPT theory, negative belief systems that a person generates following a trauma (e.g., “I am powerless,” “I am inadequate,” “The world is a dangerous place”) make it impossible to process normal emotional reactions to the catastrophic event (e.g., sadness and fear). This happens because the trauma survivor is preoccupied with inappropriate and intolerable emotions (e.g., guilt and shame) evolving from erroneous beliefs and interpretations about the traumatic experience. By confronting distorted traumatic memories, patients challenge/modify these erroneous beliefs, thereby dissipating inappropriate emotions.

CPT has both cognitive and exposure components. The exposure component differs from exposure therapy because the narratives are written by patients rather than elicited orally by the clinician. The written format gives the CPT patient more control over the pace and intensity of disclosure than is the case in exposure treatment. Recent dismantling studies have evaluated the relative contribution of the cognitive vs. exposure component to CPT. In one study, CPT that included only the cognitive component (CPT-C) was just as effective as CPT that included both cognitive and exposure components. An exception is that PTSD patients with dissociative symptoms benefitted more from the full CPT protocol in contrast to non-dissociative patients for whom CPT-C was more effective [36].

Efficacy—In studies conducted with patients having rape-related PTSD, CPT was performed as well as PE initially and 6 and 12 months after. All patients had significant reduction in all three DSM-IV PTSD symptom clusters, and none continued to meet PTSD diagnostic criteria at the 6-month follow-up. A very large face-to-face comparison between PE and CPT found both approaches equally effective. Furthermore, remission of PTSD following either PE or CPT persisted for 5 years [15, 23, 29, 31].

Originally adapted for treating rape victims, SIT provides PTSD patients with a repertoire of tools and skills they can utilize to control anxiety elicited either by trauma-related stimuli or during threatening situations [32, 33]. Unlike PE and CPT, SIT treatment does not necessarily involve a trauma-focused component. It combines a variety of anxiety management techniques including education, muscle relaxation training, and biofeedback (breathing) retraining (see page XX). In addition, SIT utilizes: [16, 31].

Positive thinking and self–talk—Clinicians teach patients how to replace negative with positive thoughts, especially when confronting stressful situations.

Efficacy—Four studies on women with rape-related PTSD or male or female motor vehicle accident survivors tested SIT (without an exposure component) alone or in combination with PE. In all cases, results from SIT were equal to those from PE, producing a 60–70 % reduction in PTSD symptom severity. Three-month follow-up assessments showed substantial improvement in one study and improvement slightly better with PE than SIT in another study [24, 29, 34, 35]. More recently, SIT has been incorporated in an Internet-based CBT protocol for US military personnel (e.g., DESTRESS) that has proven effective (see below).

Imagery rehearsal therapy (IRT) was developed to decrease the traumatic nightmares central to PTSD, reduce insomnia, and decrease PTSD symptom severity. IRT treatment consists of three weekly sessions in which patients learn cognitive behavioral techniques for replacing unpleasant nightmare images with pleasant ones. It is often delivered in a group format. The specific components of IRT are (a) psychoeducation about nightmares and PTSD, (b) anxiety management skills, (c) cognitive restructuring, (d) sleep hygiene, and (e) focused use of pleasant imagery to replace negative imagery in recurrent traumatic nightmares. Patients focus on a single, intolerable nightmare and are instructed to “change the nightmare” in any way they wish. Then they rehearse this new dream 5–20 min every day.

Efficacy—Four randomized IRT trials with crime victims, sexually abused adolescent girls and women, and Vietnam veterans have reported 50–60 % reduction in nightmare frequency and overall PTSD symptom severity [36–37]. On the other hand, a large randomized clinical trial with Vietnam combat veterans found no benefit from IRT over a credible comparison condition [38]. Further testing of IRT is clearly needed.

Biofeedback is a process to reduce tension and anxiety in which the patient is given information about her/his own physiological processes. For example, the patient is given continuous feedback about heart rate or muscle tension. She/he learns to consciously control these processes. Success is demonstrated by reductions in heart rate, muscle tension, or other physiological processes. Relaxation training is a treatment in which patients learn to relax their musculature through breathing and meditation-like tensing and untensing exercises, often assisted by audio tapes. Learning to induce muscle relaxation at will is used as a technique to control anxiety, when it occurs.

Efficacy—Biofeedback and relaxation training are ineffective stand-alone treatments but are usually included with other anxiety management techniques in CBT approaches, such as stress inoculation training (SIT) (reviewed on page. XX) [16].

Dialectical behavior therapy (DBT) is a comprehensive CBT approach designed specifically for patients with Borderline Personality Disorder, emotion dysregulation, self-destructive and suicidal behavior, impulsive behavior, substance abuse. It is also effective for otherwise unstable and difficult-to-treat patients who cannot adhere to other treatment regimens [39, 40]. Since DBT candidates often have significant trauma histories and often meet diagnostic criteria for PTSD or complex PTSD, this option may be appropriate for the initial stabilization (e.g., establishing trust and safety) phase of PTSD treatment.

See page XX for more info on establishing trust and safety.

DBT patients acquire skills to reduce chronic impulsive behavior marked by chaotic life problems, suicidal behavior, emotional lability, substance abuse, binge eating, and frequent hospitalizations. DBT is characterized by a balanced and flexible approach to therapy based on a strong patient-clinician relationship through which problem behaviors are explicitly addressed.

Efficacy—There have been no clinical trials of DBT for PTSD. Advocates of DBT for complicated PTSD patients argue that these individuals are too impulsive and disorganized to comply with a standard CBT protocol until they have been clinically stabilized through DBT. A number of reports describe moderate improvement for such complex patients receiving DBT with respect to suicidal, self-mutilating, impulsive, self-damaging, and binge-eating behaviors [39, 40, 42, 43].