411 -Cognitive Behavioral Interventions for PTSD
CEUs available at: https://allceus.com/member/cart/index/product/id/1100/c/

Dr. Dawn-Elise Snipes, PhD, LPC-MHSP
Executive Director, AllCEUs Counselor Education
Podcast Host: Counselor Toolbox Podcast, Case Management Toolbox Podcast

– Review the symptoms of PTSD
– Explore interventions in the following areas
– Cognitive: Including ACT, DBT and CPT
– Behavioral: Including exercise, sleep, nutrition and relaxation

PTSD Symptoms
– Re-experiencing the traumatic event (Intrusion)
– Intrusive, upsetting memories of the event
– Flashbacks
– Nightmares
– Feelings of intense distress when reminded
– Intense physical (panic) reactions to reminders

– PTSD symptoms of avoidance and emotional numbing
– Avoiding reminders of the trauma
– Inability to remember important aspects of the trauma
– Loss of interest in activities and life in general
– Feeling detached from others or emotionally numb
– Sense of a limited future

PTSD Symptoms
– PTSD symptoms of increased arousal
– Difficulty falling or staying asleep
– Irritability or outbursts of anger
– Difficulty concentrating
– Hypervigilance (on constant “red alert”)
– Feeling jumpy and easily startled

– Negative alterations in cognitions and mood
– Inability to recall key features of the trauma
– Overly negative thoughts and assumptions about oneself or the world
– Exaggerated blame of self or others for causing the trauma
– Negative affect
– Decreased interest in activities
– Feeling isolated

What Happens in Trauma
– When exposed to a stressor, the HPA-Axis and amygdala are activated and cortisol is released to trigger the fight or flight response
– Sustained exposure to cortisol has an adverse impact on the hippocampus resulting in reduction of neurogenesis and dendritic branching
– Blunted response to cortisol stimulation indicate that pituitary receptors in the HPA-Axis have been downregulated in patients with PTSD
– Hypocortisolism in PTSD occurs due to increased negative feedback sensitivity of the HPA axis
Neurochemical Effects of Trauma
– Early adverse experience, including prenatal stress and stress throughout childhood, has profound and long-lasting effects on the development of neurobiological systems, thereby “programming” subsequent stress reactivity and vulnerability to develop PTSD
– The hippocampus (learning and memory) and prefrontal cortex(impulse control and higher-order thought) mediate the HPA-Axis activity…but…
– Reduced volume of the hippocampus, the major brain region inhibiting the HPA axis, is a cardinal feature of PTSD
Neurochemical Effects of Trauma
– Hypocortisolism is thought to be an autoimmune response.
– Physical and psychological stress has been implicated in the development of autoimmune disease
– Hypocortisolism may occur after a prolonged period of hyperactivity of the hypothalamic-pituitary-adrenal axis due to chronic stress
– The phenomenon of hypocortisolism has been reported not only for people with PTSD, but also for healthy individuals living under conditions of chronic stress emotional and/or physical stress.
– Hypocortisolism dysfunction at the time of exposure to psychological trauma may predict the development of PTSD.
Neurochemical Effects of Trauma
– Glucocorticoids (Cortisol) interfere with the retrieval of traumatic memories, an effect that may independently prevent or reduce symptoms of PTSD.
– Therefore, hypocortisolism might be a risk factor for maladaptive stress responses and predispose to future PTSD or stress-related bodily disorders.
– Simulation of a normal circadian Cortisol rhythm using exogenously introduced hydrocortisone is effective in the treatment of PTSD.
Neurochemical Effects of Trauma
– Core neurochemical features of PTSD include abnormal regulation of dopamine and norepinephrine, serotonin and opioid neurotransmitters, each of which is found in brain circuits that regulate/integrate stress and fear responses
– A cardinal feature of patients with PTSD is sustained hyperactivity of the autonomic nervous system, as evidenced by elevations in heart rate, blood pressure, and other psychophysiological measures
– Patients with PTSD exhibit increased heart rate, blood pressure, and NE responses to traumatic reminders sustaining the stress response even in nonthreatening situations.
Neurochemical Effects of Trauma
– Chronic exposure to stressors induces upregulation of 5HT2 and downregulation of 5HT1A receptors in animal models and downregulation of HPA-Axis response to acute stressors.
– 5HT2: Anxiety, Appetite, Cardiovascular Function, GI Motility, Alertness/sleep, Vasoconstriction (Atypical antipsychotics, sleep aids)
– 5HT transmission may contribute to symptoms of PTSD including hypervigilance, increased startle, impulsivity, and intrusive memories

Healing the Body and the Brain.
– Hypocortisolism is a key feature in PTSD
– Hypocortisolism results from an autoimmune reaction
– Autoimmune reactions are triggered or worsened by stress
– People with PTST may have excesses of dopamine, norepinephrine and insufficient serotonin at the HT1 receptor
– Cognitive behavioral treatment goals would be aimed at reducing physical and psychological stress including
– Improving nutrition
– Reducing stimulant exposure
– Improving sleep
– Addressing cognitive issues that maintain the stress response

– Sleep
– Nutrition
– Hydration for cellular function
– Exercise for oxygenation and increases in Serotonin 5HT1
– Eliminate unnecessary stressors
– Do things that you enjoy (relax) and laugh often.
– Laughter boosts the immune system and reducing dangerous stress hormones in the body.

– Environmental Grounding
– Use Feng Shui principles to eliminate unnecessary stress (feeling trapped, getting startled)
– Keep a light with a red light bulb (or yellow if red is a trigger) by the bed
– If a nightlight is needed, ensure it is no more than 5 watts and is yellow or red to minimize disruption to circadian rhythms
– Get a dog (Emotional support animal)

– Understanding
– When people see how their symptoms make sense, it is easier to deal with them
– Avoidance
– Hypervigilance
– Intrusion
– Negativity
– Many people who experience trauma have difficulty integrating that trauma into their schema so they get stuck in a fear (I told you so)-loop
Telling Their Story
– Clients often need to tell their story
– It is very difficult to relive that experience while looking someone else in the eye and sitting still.
– Ensure the client has something to focus on.
– Bouncing a tennis ball against the wall or a basketball with you.
– Some people prefer to swing and look at an object like a windchime
– Some prefer be doing something they enjoy like cooking, exercising
– Make sure the client feels safe
– Continually use past-tense words and reaffirm for the client they are safe in the present
– That was overwhelming for you at that age.
– When you were deployed you were constantly on edge
Then and Now
– Help clients identify how they are different/less vulnerable now.
– Help clients identify the ways the trauma changed
– How they feel about others (strangers, family, kids)
– How they feel about themselves
– Their outlook
– Help them address any cognitive distortions by
– Finding the exception
– Getting the facts
Cognitive Distortions

– Evaluate how thinking errors can play into basic fears: Rejection, isolation, the unknown, loss of control, failure
– Mindreading (F)
– I can tell that person is dangerous/wants to hurt me
– All-or-Nothing/Polarized (E)
– I will never feel safe again
– Catastrophizing (F)
– My life is over. I am ruined.
– Overgeneralization (E)
– People like that are dangerous/want to hurt me
– Shoulds (F)
– I should have known
– Recency/Availability Heuristic (F)
– It is not safe to be in parking garages/high rises/festivals….

Constructive Self-Talk
– Help clients develop survivor scripts
– Button pins, collage, ribbon tree
– I should have –> I did the best I could
– I am broken – I am changed AND lovable/stronger
– I am weak –> I survived things not everyone has to experience
– I am
Tree Metaphor

– Keeping a log of flashbacks/startle responses
– When they occurred
– What triggered it (if known)
– Intensity on a scale from 1-5
– Sleep the prior night
– Amount of caffeine/alcohol/nicotine in the preceding hours
– Prior stressors that day
– Use logging to
– Chart the reduction in frequency and/or intensity of intrusive or hypervigilant symptoms
– Identify triggers or vulnerabilities for flashbacks or startle responses
– Effective for anxiety, negativity
– Activating Event (What happened)
– Beliefs
– Obvious
– Negative self-talk/Past tapes
– Consequences
– Dispute Irrational Thoughts
– Evaluate the Most Productive Outcome
– Is this worth my energy-
– How can I best use my energy to deal with or let go of the situation-
Systematic Desensitization (Intrusion)

– Identify a feared situation (Being at home alone during the day)
– Imagine it
– Rate your anxiety on a scale from 1-5
– Use deep breathing, grounding/mindfulness skills until you can imagine it and not feel bothered
– Do something a little more anxiety provoking. (Being at home alone for 10 minutes after everyone leaves in the morning)…
– Stay home alone during the day for 30 minutes when your neighbor/friend
– Stay home alone during the day for 1 hour
– Stay home alone until it gets good and dark
– Stay home alone after dark
– Go to sleep when you are home alone
Dialectical Behavior Therapy

– Effective for anxiety, negativity, withdrawal/avoidance, intrusion
– Preventing vulnerabilities (Behavioral)
– Mindfulness
– To prevent vulnerabilities
– To prevent or mitigate triggers (i.e. grounding)
– Distress is inevitable
– Develop Distress Tolerance skills
– Urge surfing
– Activities, Comparisons, Contributing, Emotions, Pushing Away, Sensations
– Imagery, Meaning, Prayer, Relaxation, One Thing, Vacation, Encouragement
– Embracing dialectics
Acceptance and Commitment Therapy

– Effective for anxiety, negativity, withdrawal/avoidance, intrusion
– Acceptance– It is what it is
– Fusion with thoughts– I am having the thought that…
– Define goals and values
– Choose purposeful action
– Live in the And…

Cognitive Processing Therapy

– Effective for anxiety, negativity, withdrawal/avoidance
– Facts for and against
– Is your belief based in facts, emotions or habit-
– Are you using cognitive distortions*-
– Are you focusing on only one aspect of the event-
– Are you confusing high and low probability-
– Are you focusing on irrelevant factors-
– Is this thought getting you closer to what you want-
– What are the advantages/disadvantages to thinking this way-
– What difference will this make in a month/year-

– Trauma impacts the person biopsychosocially
– Behavioral interventions can help them prevent and address avoidance and hypervigilance
– Cognitive interventions can help them
– Understand the function of their symptoms to choose effective ways of dealing with them
– Address unhelpful cognitions about the trauma, themselves and the world
– Reduce chronic stress to help the HPA-Axis rebalance and recover
– Assist in integrating the trauma narrative so it is not a “loose end.”