Cognitive Processing Therapy (CPT) for Trauma and PTSD

Phobia Release Program

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Phobia Release Program Summary


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Ptsd And Fast Phobia Relief Self-help Audio Program

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Ptsd And Fast Phobia Relief Selfhelp Audio Program Summary

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Posttraumatic stress disorder

Posttraumatic stress disorder posttraumatic stress disorder (PTSD) is a common, frequently chronic condition that occurs following life-threatening or horrific traumatic events. The lifetime incidence of PTSD in western societies is 10-15 and approximately 50 of individuals who have had an episode of PTSD develop chronic symptoms. Family and twin studies suggest a substantial genetic contribution to the pathogenesis of PTSD (Radant et al. 2001). However, PTSD is unique among psychiatric disorders since there is an explicit requirement for the presence of a precipitating environmental event. While some types of trauma exposure (e.g. natural disasters, assaults) are not influenced by individual characteristics, other types of trauma exposure may be associated with certain personality characteristics (e.g. engaging in high-risk activities) which are themselves under genetic influence. as well as genetic heterogeneity, incomplete penetrance, pleiotropy, and interaction multiple genes...

Post Traumatic Stress Disorder

Core features of HPA axis changes in PTSD include low basal cortisol secretion and enhanced negative feedback control of the HPA axis (Yehuda 2002). The enhanced negative feedback was found using low-dose dexamethasone (0.25 mg) or metyrapone tests. Blunted ACTH responses to CRF stimulation are explained by downregulated CRFR1, possibly as a result of sustained, increased endogenous CRF levels. However, findings have not been consistent. Differences could involve disease stages, gender, genetic background, or type of trauma among others. Using the combined Dex-CRF test did not reveal HPA-axis abnormalities in PTSD patients when compared to trauma controls (also exposed to trauma but without PTSD). However, PTSD patients with a comorbid MDD showed an attenuated ACTH response compared to PTSD patients without comorbid MDD. This indicates the presence of PTSD subgroups with different HPA-axis regulation.

Should Every Chronic Pain Patient Be Assessed Psychologically

The other side of the argument, however, is based on clinical experience as well as research. Almost all practicing pain management specialists today would agree that there is a high incidence of comorbid psychopathology associated with chronic pain, such as depression and posttraumatic stress disorder. Treating the emotional disorder often helps the pain disorder quite significantly, while not treating the psychiatric disorder hampers improvement of the physical pain, regardless of the medical intervention. Additionally, and quite powerfully, there is a growing body of literature showing that most predictors of treatment success with interventional procedures are psychological, while most predictors of treatment failures are also psychological.

HT2CRMediated Contributions to Affective Behaviors

Immunocytochemistry) following footshock when compared with wild-type littermates (Bonasera et al. 2005). These studies suggest that 5-HT2CRs on populations of BNSt projection neurons are required to appropriately activate circuits within the extended amygdala that inhibit the expression of motor responses to unconditioned anxiogenic and aversive stimuli. These 5-HT2CR-expressing extended amygdala neuronal populations may prove to be important targets of therapeutic interventions designed to treat highly prevalent and disabling anxiety conditions, such as generalized anxiety and posttraumatic stress disorder.

Pharmacological Properties

Response in the endocrine, autonomic, immune, and behavioral systems through the activation of the hypothalamic-pituitary-adrenal (HPA) axis and extrahypothalamic pathways. The peptide itself is highly conserved between species, and its evolutionary role is to mobilize energy stores and appropriate behavior(s) in response to a stressor. It has since evolved to regulate a variety of responses to stress. CRF was first isolated and characterized by Vale and colleagues in 1981. Due to the similarity in sizes of ACTH and CRF and limits on detection techniques, purification was performed on approximately 490,000 sheep (ovine) hypothalami in order to generate enough samples for isolation. This was part of an ongoing study elucidating a variety of hypotha-lamic peptides. In the majority of studies, the CRF system has consistently been shown to be dysregulated in many patients suffering from a variety of psychiatric illness including post-traumatic stress disorder (PTSD), early life trauma,...

Characterization Of Depressive And Anxiety Disorders

The primary clinical manifestations of major depression are significant depression of mood and impairment of function. Some features of depressive disorders overlap those of the anxiety disorders, including panic-agoraphobia syndrome, severe phobias, generalized anxiety disorder, social anxiety disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. Extremes of mood also may be associated with psychosis, as manifested by disordered or delusional thinking and perceptions that often are congruent with the predominant mood. Conversely, secondary changes in mood may be associated with psychotic disorders. This overlap of disorders can lead to errors in diagnosis and suboptimal treatment. Mood and anxiety disorders are the most common mental illnesses, each affecting up to 10 of the general population at some time in their lives.

Psychoneuroendocrinology Introduction

Major depression is considered to be a maladaptive, exaggerated response to stress, and although it is accompanied by abnormalities in multiple endocrine systems, it is the hypothalamic-pituitary-adrenal (HPA) axis that is the main component of the physiological stress response that plays the key role. Stressful life events, particularly those related to loss, have a strong causal relationship with depressive episodes. However, not all people who experience such events develop depression, and an individual's vulnerability to depression depends on the interaction of genetic, developmental, and environmental factors. In addition to the role of the HPA axis in depression, there is growing evidence of HPA axis abnormalities in anxiety disorders and posttraumatic stress disorder (PTSD).

Sociodemographic factors

The mechanisms of gender differences in FMS are not fully understood. An interaction between biologic, psychological and sociocultural factors has been postulated 41 . Between puberty and menopause, adult women usually show lower responses of the hypothalamic-pituitary-adrenal axis (HPA) and autonomic responses than men of the same age 42 . Female gender is a risk factor for psychologic distress and some mental disorders (affective and anxiety disorder, PTSD) which are associated with FMS. Functional somatic syndromes

Glucocorticoid Receptor

A transcription factor regulating the CRF gene. Glucocorticoid receptors (GR) are stabilized in the cytosol by various chaperones before homodimerizing and translocating into the nucleus. Childhood abuse and polymorphisms in FKBP5, a chaperone for GR, are associated with posttraumatic stress disorder.

Nonpharmacological Options

Non-pharmacologic options for trauma patients include transcutaneous electrical nerve stimulation (TENS), acupuncture, and relaxation techniques. In general, these therapies tend to be most useful as adjuncts to either nerve blocks or pharmacotherapy or in patients with mild pain. Relaxation techniques such as guided imagery, self-hypnosis, and biofeedback are most beneficial in patients with high anxiety levels, whereas the best candidates for eye movement desensitization and reprocessing (EMDR) and cognitive-behavioral therapies are cognitively intact patients willing to take an active role in treatment. The treatment of coexisting psychopathology is critical to optimizing pain treatment outcomes and should not be underestimated. In fact, long-standing anxiety from poorly managed pain has been associated with depression and posttraumatic stress disorder.

PET Tracers of Cerebral Metabolism and Blood Flow

PET has been used to assess functional activity of brain regions, both in the resting state and in response to various stimuli. The methods used include use of FDG-PET and radioactive 15O H2O-PET to study metabolic activity and blood flow, respectively. Figure 10-2A shows a picture of increased cerebral blood flow to paralimbic regions during a sad mood induction task (to be described later) using H2O-PET. In contrast, Figure 10-2B shows metabolic activity differences among depressed versus healthy patients using FDG-PET. These modalities have been effectively used to study a variety of mental phenomena and have been of considerable benefit in enhancing our understanding of psychiatric disorders. Of particular interest have been studies using PET to understand the biological basis of schizophrenia (Fujimoto et al. 2007 Lange et al. 2005), bipolar disorder (Post et al. 2003), depression (Mayberg 2003b Neumeister et al. 2004), substance abuse and craving (Kilts et al. 2004), PTSD...

Neuroendocrine Alterations

In patients with FMS, a reduced hypothalamic-pituitary-adrenal (HPA) axis response to stress has been demonstrated.41,42,43 The neuroendocrine response acts normally under baseline conditions, but not when subjected to stress or even normal activities of daily living. However, this deficit might have more impact on depression, a common associated feature of FMS as well as chronic pain. Patients with FMS often report experiencing previous stressful or traumatic events. A reduced HPA axis response to stress can contribute to FMS development or worsening of FMS. The HPA axis is also linked to the autonomic nervous system, which is involved in modulating sleep, mood, pain, and cardiovascular activities (including microcirculation of muscles). This could explain many clinical features and the association of FMS with sympathetic nerve system over activity, although more detailed mechanistic studies will be needed to confirm a causative relationship. Abnormal HPA axis activity has also been...

History And Discovery

Shortly after the introduction of fluoxetine into the U.S. market in 1988, a marked increase in research led to the development of other SRIs, which ultimately proved effective in a wide array of psychiatric disorders. Paroxetine was the third SRI approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression. Since then, it has also attained approval by the FDA for the treatment of all five DSM-IV-TR (American Psychiatric Association 2000) anxiety disorders panic disorder, OCD, PTSD, social anxiety disorder, and GAD. Paroxetine is available in 10-, 20-, 30-, and 40-mg tablets and in suspension form. A controlled-release (CR) formulation is available in 12.5-, 25-, and 37.5-mg tablets. It exhibits equal or better efficacy than the paroxetine immediate-release (IR) formulation, as well as clear advantages in tolerability (Golden et al. 2002).

The anxiety disorders

Recent studies have begun to confirm the widely held hypothesis that caffeine can be a contributing factor in the maintenance, and perhaps even genesis, of some anxiety disorders. Included are post-traumatic stress disorder (PTSD),223 phobia,304,305 obsessive-compulsive disorder,306 and panic dis-order.307-309 One study showed, for example, that excessive caffeine consumption is a common factor in the PTSD reactions seen in combat troops. Based on their results, the investigators recommended decaffeinated beverages for all troops entering combat situations.223

Dibenzocycloheptenes And Dibenzocycloheptanes

Cyproheptadine possesses both antihistamine and anti-serotonin activity and is used as an antipruritic agent. It is indicated for the treatment of hypersensitivity reactions, perennial, and seasonal allergic rhinitis vasomotor rhinitis allergic conjunctivitis, uncomplicated allergic skin manifestations of urticaria and angioedema amelioration of allergic reactions to blood or plasma and cold urticaria. It is also used off-label for nightmares associated with posttraumatic stress disorder (PTSD), prevention of migraine, suppression of vascular headaches, and appetite stimulation. Sedation is the most prominent side effect, and this is usually brief, disappearing after 3 or 4 days of treatment.

Generalized anxiety disorder

Generalized anxiety disorder (GAD) is defined by excessive and uncontrollable worry about a number of life events or activities for least 6 month, accompanied by at least 3 of 6 associated symptoms of negative affect or tension, such as restlessness, fatigability, concentration difficulties, irritability, muscle tension, and sleep disturbance. Relative to other anxiety and mood disorders, GAD is more likely to show a gradual onset and or life-long history of symptoms. While early ages of onset are common, the syndrome itself may emerge only later in life and a considerable number of patients with GAD report an onset in adulthood that is usually in response to psychosocial and emotional stress. Research has consistently shown that GAD is associated with high comorbidity rates for other psychiatric disorders, including panic disorder, major depression, dysthymia, social phobia, and specific phobia (Kendler et al. 1992a Kendler et al. 1995a Roy et al. 1995 Skre et al. 1994 Weissman...

Caffeine and effect

The interaction of caffeine and stress One of the major contributing factors in anxiety and the anxiety disorders is stress, and it is reasonable to hypothesize that this is an area of psychological functioning in which caffeine may be implicated.16 Ongoing research has clearly demonstrated the destructive psychological and physiological effects of stress. One of the most serious reactions is post-traumatic stress disorder (PTSD), which was reported at least as far back as 1755 when a peasant family was trapped by an avalanche in the Italian Alps.216 It has been widely studied in Vietnam veterans217,218 and in veterans of World War II and the Korean War.219 In civilians, PTSD is seen in 38 of burn victims220 and 46 of those involved in motor vehicle accidents.221 More generally, a study of college students revealed that any of a wide variety of prior traumatic experiences could produce the symptoms of PTSD.222 There is now some evidence that caffeine may be a contributing factor in...

Role of Pharmacotherapy

As stated earlier, the adjustment disorders are a product of stressor(s) in a person's life, that is, the precipitating event for this psychiatric disorder is one or more exogenous stressor. It is one of those psychiatric disorders for which an etiology is known. It is assumed that once the stressor is terminated or the patient adjusts to the stressor, the adjustment disorder symptoms, e.g., disturbance of mood or conduct, will also terminate. However, some stressors do not abate, e.g., chronic medical illness, joblessness, financial distress, etc., and the patient may continue to have an adjustment disorder in excess of 6 months. Thus, adjustment disorders join that group of disorders that also have exogenous stressors as the key etiological agent, e.g., acute stress disorder and posttraumatic stress disorder. These stress-related disorders, the organic mental disorders and the substance abuse disorders, for all of which an etiology can be identified, are thus differentiated from the...

Paroxetine Introduction

Paroxetine (Paxil) is classified as one of the serotonin reuptake inhibitors (SRIs) because of its potent inhibition of presynaptic serotonin (5-HT) uptake. It is also a relatively potent norepinephrine (NE) reuptake inhibitor, particularly at higher doses, leading some to argue for its inclusion in the growing class of acknowledged dual serotonin-norepinephrine reuptake inhibitors (SNRIs). Since its approval for the treatment of depression, paroxetine has been demonstrated to be effective and has been approved for a broad spectrum of anxiety disorders, including panic disorder, obsessive-compulsive disorder (OCD), social anxiety disorder, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). Moreover, studies have demonstrated the efficacy of paroxetine in premenstrual dysphoric disorder (PMDD), postmenopausal hot flashes, and child and adolescent OCD and social anxiety disorder. Paroxetine is still one of the most prescribed antidepressant medications in the...

Other Psychiatric Disorders and the Immune Response

Some evidence suggests that other stress-related neuropsychiatric conditions may be associated with immune activation, although these conditions are less well characterized than major depression. These disorders include posttraumatic stress disorder (PTSD), chronic fatigue syndrome (CFS), seasonal affective disorder (SAD), and fibromyalgia. Patients with combat-related PTSD have been reported to demonstrate increased plasma concentrations of IL-1 and increased CSF concentrations of IL-6 (Baker et al. 2001 Spivak et al. 1997). PTSD following civilian disasters appears to be associated with elevated plasma concentrations of IL-6 and its soluble receptor (Maes et al. 1999c). Although not found consistently (Maes et al. 1999c), both severity of symptoms and duration of illness have been reported to correlate positively with indices of immune activation in PTSD (Miller et al. 2001 Spivak et al. 1997).

Pharmacotherapy Of Anxiety

Anxiety is a symptom of many psychiatric disorders and an almost inevitable component of many medical and surgical conditions. Symptoms of anxiety commonly are associated with depression and especially with dysthymic disorder (chronic depression of moderate severity), panic disorder, agoraphobia and other specific phobias, obsessive-compulsive disorder, eating disorders, and many personality disorders. Sometimes, no treatable primary illness is found, or if one is found and treated, it may be desirable to deal directly with the anxiety at the same time. In such situations, antianxiety medications are frequently and appropriately used. Antidepressants tend to provide a more sustained and continuous improvement of the symptoms of attention-deficit hyperactivity disorder than do the stimulants and do not induce tics or other abnormal movements sometimes associated with stimulants. Indeed, desipramine and nortriptyline may effectively treat tic disorders, either in association with the...

Structured clinical interview

Patients with chronic pain often have a traumatic onset etiology. A significant number of patients seen by chronic pain specialists may therefore experience considerable amounts of psychological distress and some may have posttraumatic stress disorder (PTSD). PTSD has been estimated to occur in about 10 percent of chronic pain patients. When patients with pain as a result of an accident are referred for psychological treatment, the reported PTSD rates increases from 50 to 100 percent. The failure to diagnose and treat PTSD properly in chronic pain patients can lead to minimal or inadequate pain relief. A useful assessment measure for patients with chronic pain and trauma is the Posttraumatic Chronic Pain Test (PCPT).13 The PCPT contains six true-false items that evaluate the presence of PTSD related to the accident that caused the patient's pain. The clinical interview also affords the opportunity to evaluate the patient's beliefs and cognitions about their pain. However, the primary...

The Alcohol Addictive Patient

Driving under the influence or a history of two or more non-sport-related traumatic events (after age 18 years) are considered at high risk for substance abuse 42 . Therefore, the prescribing physician should be alert to the eating disorder, addiction, and sexual abuse triad - if two are present, look for the third 49 . It is because of this triad that researchers have recommended that all women entering substance abuse treatment should be screened for eating disorders 50 . During the initial assessment ask for the following

Key Learning Points

Depression and anxiety are the most common psychiatric illnesses affecting people with chronic pain. In many cases, it is appropriate to treat depression with antidepressant drugs, particularly if there is pervasive loss of pleasure. The selective serotonin reuptake inhibitor (SSRI) drugs are usually employed first, but tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRI) drugs are more appropriate if there is evidence of a neuropathic pain state. Posttraumatic stress disorder is a poor prognostic sign in people with chronic pain who have developed pain following an injury.

Mental Retardation

Anxiety disorders can be difficult to diagnosis in MR individuals because of the necessity of subjective complaints. However, by observing patients, symptoms such as avoidance, autonomic arousal, psychomotor agitation, or irritability can help to clarify the diagnosis (Madrid et al. 2000). Specifically, posttraumatic stress disorder should be considered in the differential diagnosis. Individuals with MR are an inherently vulnerable population they have difficulty reporting events and often want to please their caretaker (Szymanski and King 1999).

Stress disorders

Posttraumatic stress disorder (PTSD), and adjustment disorder. Acute stress reactions and PTSD develop in response to exceptionally threatening experiences, but acute stress subsides within days (and is not considered further), whereas PTSD is more prolonged. This disorder consists of persistent, intrusive recall or reenactment of the traumatic event in memories, dreams, and flashbacks. Restriction of the emotions, avoidance of situations that might provoke memories of the trauma, and increased arousal to particular perceptual stimuli, e.g. sudden loud sounds, are associated symptoms. There is clear evidence that the experience and management of pain can be aggravated by PTSD. One of the main reasons for this is because PTSD is associated with high anxiety and we have seen that anxiety is associated comorbidly with chronic pain.26 Furthermore, the presence of PTSD is a poor prognostic sign.44'45 Hyper-arousal, excessive attention to changes in the environment, and an inclination to...


Several multisite clinical trials have established approximate equivalent efficacy of all marketed antidepressants, with the clinically relevant differences related to adverse effects, ease of dosing, and safety. SSRIs remain the first-line agents under most circumstances, with mixed action, TCAs, heterocyclics, and MAOIs additional options. Antidepressants are effective across a range of disorders including depression, PTSD, anxiety, and chronic pain. Combination and augmentation therapies have been developed for depressions that are resistant to monotherapy, although evidence to date does not favor a specific approach. Novel treatments, whether developed from herbal preparations or new chemical compounds, are an exciting area for further research, but data supporting their efficacy and safety are limited. Combinations of antidepressants with Transcranial Magnetic Stimulation offers another potential augmentation strategy, however there is a paucity of data addressing this approach.


Anxiety is a very common concomitant condition in patients with chronic pain, presenting as panic, PTSD, obsessive compulsive disorder (OCD), etc. Although anxiolytics do not possess intrinsic analgesic activity, anxiety is often accompanied by somatic complaints of chest pain, GI upset, or neurologic symptoms such as dysesthesias, headache, which may be relieved by anxiolysis. Benzodiazepines are also a mainstay in the treatment of restless legs syndrome (RLS). Although most RLS studies were conducted with clonazepam, current recommendations focus on shorter acting benzodiazepines such as triazolam (Silber et al. 2004).

SSRIs History

As clinical experience with SSRIs has grown, it has become apparent that they have their own share of adverse effects. Also, the equivalence of SSRIs' efficacy to TCAs' has been challenged, and still remains a matter of some controversy. Even with these concerns, SSRIs are widely used and are effective in a wide range of psychiatric disorders other than depression, such as anxiety disorders, obsessive-compulsive disorder (OCD), panic disorder, bulimia nervosa, social phobia, posttraumatic stress disorder (PTSD), premenstrual dysphoric syndrome (PMDS), dysthymia, and seasonal affective disorder. SSRIs are the most widely prescribed antidepressants in America and worldwide (32).


Neurotransmitter alterations in PTSD catecholamines and serotonin. Semin Clin Neuropsychiatry 1999 4(4) 242-8. between thyroid hormones and symptoms in combat-related posttraumatic stress disorder. Psychosom Med 1995 57(4) 398-402. Enhanced suppression of cortisol following dexamethasone administration in posttraumatic stress disorder. AmJPsychiatry 1993 150(1) 83-6. volume in patients with combat-related posttraumatic stress disorder. Am J Psychiatry 1995 152 973-81. hippocampal volume in chronic, combat-related post-traumatic stress disorder. Biological Psychiatry 1996 40 1091-9. volume in posttraumatic stress disorder related to childhood physical and sexual abuse-A preliminary report. Biological Psychiatry 1997 41 23-32. acetylaspartate in post traumatic stress disorder. The Annals of the New York Academy of Sciences 1997 Supplement on Psychobiology of Posttraumatic Stress Disorder(821) 516-20. resonance spectroscopy of the medial temporal lobes of subjects with combat-related...


In his review article of available pharmacological treatments for PTSD, Davidson cites evidence from large long-term clinical trials of SSRI antidepressants' efficacy in patients with this disorder (130). In chronic PTSD, we have found that the combination of SSRIs and atypical antipsychotics produces the best effects (see also Chapter Antidepressants in the Treatment of PTSD ). To summarize, the SSRI antidepressants remain the first-line treatment for major depression, dysthymia, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social phobia, PTSD, and bulimia. They have a favorable side effect profile as compared to older antidepressants, better patient tolerability, ease