Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder

  • Foa E
  • Rauch S
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Abstract

The authors report on changes in cognitions related to posttraumatic stress disorder (PTSD) among 54 female survivors of sexual and nonsexual assault with chronic PTSD who completed either prolonged exposure alone or in combination with cognitive restructuring. Treatment included 9 –12 weekly sessions, and assessment was conducted at pretreatment, posttreatment, and a modal 12-month follow-up. As hypothesized, treatment that included prolonged exposure resulted in clinically significant, reliable, and lasting reductions in negative cognitions about self, world, and self-blame as measured by the Posttrau-matic Cognitions Inventory. The hypothesis that the addition of cognitive restructuring would augment cognitive changes was not supported. Reductions in these negative cognitions were significantly related to reductions in PTSD symptoms. The addition of cognitive restructuring did not significantly augment the cognitive changes. Theoretical implications of the results are discussed. Adapting the emotional processing theory of anxiety to post-traumatic stress disorder (PTSD), Foa and Rothbaum (1998) pro-posed that two basic dysfunctional cognitions mediate the devel-opment and maintenance of PTSD: The world is completely dangerous (e.g., it is too dangerous to live alone), and I am totally incompetent (e.g., I can't handle any stress). Consistent with the emotional processing theory, Foa, Ehlers, Clark, Tolin, and Orsillo (1999) found that individuals with current PTSD perceived the world and themselves as more negative and reported more trauma-related self-blame than did nontraumatized individuals and indi-viduals who had been traumatized but did not have PTSD. Foa and Cahill (2001) proposed that immediately after traumatic events, survivors adopt an extreme view about the dangerousness of the world and their inability to cope with threat and stress. They suggested that for most survivors, these negative cognitions get disconfirmed and thus corrected through engagement in daily activities and processing of the traumatic memory. However, those who avoid trauma-related thoughts and activities continue to hold the posttrauma negative cognitions that foster the development of chronic PTSD. Foa and Rothbaum (1998) suggested that similar processes are at work in prolonged exposure (PE) therapy. Indeed, PE involves systematic repeated confrontation with the traumatic memories (imaginal exposure) and with avoided trauma-related situations (in vivo exposure). Foa and Rothbaum posit that these exposures present clients with information that disconfirms the negative PTSD-related cognitions and thereby ameliorates PTSD symptoms. In contrast, cognitive therapists have emphasized the role of cognitive changes during therapy, suggesting that in addition to exposure, treatment of PTSD should contain specific cognitive procedures that directly aim at altering PTSD-related cognitions (Resick & Schnicke, 1992; Steil & Ehlers, 2000). We examined in the present study the hypotheses that PTSD-related negative cognitions will decrease with treatment that in-cludes PE and that treatment that includes both PE and cognitive restructuring will modify PTSD-related cognitions more than PE. Specifically, we predicted that cognitions about world and self (including self-blame) would be less negative following PE plus cognitive restructuring (PE–CR) than following PE. We further hypothesized that reductions in these PTSD-related negative cog-nitions would be associated with reductions in PTSD symptom severity. In addition, we examined the relative contribution of reduction in negative cognitions about self, world, and self-blame to reduction in PTSD symptom severity via regression analyses.

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