The European Network for Traumatic Stress
Training & Practice
Cognitive Therapy and the
treatment of PTSD and ASD
Chris Freeman MD
 What is CBT
 General principles of psychological treatment
 A typical course of treatment
 Evidence base for CBT in PTSD
 Evidence base for CBT in Acute stress disorder
 CBT compared with other psychological
treatments and drugs
What is CBT
• Several different models of CBT but all share
some common characteristics
• Even EMDR has some CBT principles but it will
be covered in a separate set of slides
• Brief Eclectic Therapy (BEP) has some CBT
techniques but is a separate psychotherapy
despite being grouped with CBT by NICE.
(National Institute of Clinical Excellence UK)
General principles of psychological
• Assessment and formulation is crucial
• This should be carried out before ASD and
PTSD treatment.
CBT for PTSD. The Evidence
Ways of changing trauma memories : How
CBT models differ.
• Prolonged exposure to trauma memory (Foa: imaginal
reliving; Resick: trauma narrative)
• Updating worst moments in memory (Ehlers & Clark)
• Brief exposure to image with rapid eye movements or
other bilateral stimulation (Shapiro)
• In vivo exposure
• Discrimination of triggers (Ehlers & Clark)
Evidence Base reviewed by NICE
• EMDR: 11 studies compared with W/L or other
psychological interventions
• CBT: 16 studies compared with W/L or other
psychological interventions
• ECBT: 16 studies compared with W/L or other
psychological interventions
• SM: 7 studies compared with W/L or other psychological
• GCBT: 4 studies compared with W/L or other
psychological interventions
• Other: 6 studies compared with W/L or other
psychological interventions
NICE Guidelines 2005: Systematic Review of
Psychological Treatments for PTSD –
Effect sizes compared to wait list
13 RCTs
4 RCTs
CBT: Stress
3 RCTs
A priori threshold d = .08
2 RCTs
Psychological Interventions
• Exposure based CBT demonstrated more
clinically important effects on self report PTSD
symptoms and PTSD diagnosis than W/L.
• Limited evidence of superiority on clinician rated
PTSD symptoms , depression and anxiety
• Not superior to stress management or other
treatments and outcomes varied substantially
Psychological Interventions
• EMDR found support but not as strong as
• Clinically important benefits on clinician rated
but not self report PTSD symptoms compared to
• Limited evidence for clinically important effects
on anxiety and depression
• EMDR was superior to supportive/non-directive
therapy but not stress management.
Evidence base since NICE
• Several new studies but no change in
conclusions above
• 4 additional studies comparing trauma
focussed CBT with waiting list
• I additional study comparing trauma
focussed CBT with other treatment
Recommendations from evidence base: 1
• All PTSD sufferers should be offered a course of
trauma focused psychological therapy on an
individual, out-patient basis (A)
• Trauma focused psychological interventions
should be offered regardless of the time elapsed
since the trauma (B)
Recommendations from evidence base: 2
• CBT should be offered even if key trauma was a
long time ago
• Individual face to face therapy is first choice
• Course of treatment for a single trauma is 8-12
60 min. sessions
• Treatment must be flexible with longer sessions
if trauma story being related.
Recommendations from evidence base: 3
• Trauma focused psychological interventions
should be 8-12 sessions long when the PTSD
has arisen from a single incident. (B)
• If the traumatic event is being discussed
sessions should be longer (90 mins), offered on
a regular and continuous basis (weekly) with the
same person. (B)
Recommendations from evidence base: 4
• In cases of multiple trauma, traumatic
bereavement, chronic disability arising from the
trauma, significant co-morbidity or social
problems longer treatment duration should be
considered (> 12 sessions). (C)
• Treatment should be delivered by competent
individuals with appropriate training and
supervision. (C)
Acute Stress Disorder (ASD)
• Evidence recently reviewed by Roberts 2009
• Evidence supports effectiveness of trauma focussed
CBT over control
• Self help booklets are not superior to control condition
(Ehlers 2003)
• Studies that offer brief treatment (5 sessions) treat ASD
and PTSD symptoms but not depression or anxiety.
• Need longer treatment 12 hours + to treat wider
Acute Stress Disorder
• Studies have tended to treat patients in
first 3 months so subjects are a
combination of ASD and acute PTSD
• Evidence base is very similar to PTSD but
fewer studies
• Sessions should be 90 minutes long if
using imaginal exposure
• Combination treatments should not be
• Treatment should be individual not group
• Treatment should not begin within 2 weeks
of the trauma
Training for therapy
• Used to assumed that therapists needed
to be competent in general CBT and then
trained in Trauma Focussed CBT
• Northern Ireland studies show this may not
be necessary
Drug treatment compared with
• No head to head trials so we have to
assess drug trial evidence separately and
compare at a clinical level
What are essential ingredients
Trauma focussed
Target trauma memories
Target trauma beliefs and meanings
Provide exposure
Provide a safe secure setting
Drop out rates: different CBT models compared
• Different psychological treatments may not
differ much in symptom reduction
• They do differ significantly in acceptability
General points on effectiveness of CBT
(effectiveness v.s. efficacy)
• 67% of those who complete treatment no longer meet
PTSD criteria
• But: pre post symptom scores negatively correlated with
drop out rates indicating that those who don’t improve
may drop out
• Trials exclude approx. 30% of referrals which is lower
than for other diagnoses e.g.. Depression
• Combat related PTSD consistently shows poorer

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