An estimated 50% to 60% of individuals in the United States will experience at least one traumatic event in their lifetime (e.g., Kessler et al., 1995 and Ozer et al., 2003). In the immediate aftermath of a trauma, symptoms of posttraumatic stress disorder (PTSD), including reexperiencing of the trauma (e.g., intrusive thoughts, nightmares, flashbacks), emotional numbing (e.g., feelings of detachment, disinterest, and restricted range of affect), avoidance of trauma cues, and symptoms of excessive arousal (American Psychiatric Association [APA], 2000) are quite common. However, these symptoms tend to decline naturally in the first 3 to 6 months following the event (Blanchard et al., 1995, Delahanty et al., 1997, Ehlers et al., 1998, Rothbaum et al., 1992 and Valentiner et al., 1996), with some survivors of trauma even making positive changes in their lives (e.g., Linley & Joseph, 2004). Unfortunately, not all survivors follow a trajectory of recovery and/or growth after the event, with between 5% and 30% going on to develop chronic PTSD (e.g., Breslau et al., 1998, Kessler et al., 1995 and Ozer et al., 2003).
As a whole, cognitive behavioral therapy (CBT) for PTSD has been recommended by the International Society for Traumatic Stress Studies (Foa, Keane, & Friedman, 2000), the APA (Ursano et al., 2004), the National Institute for Clinical Excellence (Bisson et al., 2005), and the Departments of Veterans Affairs and Defense (2003) as the standard of care for PTSD. Further, large treatment effect sizes are noted with CBT for PTSD in meta-analytic reviews (e.g., Butler, Chapman, Forman, & Beck, 2006). However, even with PTSD being considered a treatable disorder (e.g., Bradley, Greene, Russ, Dutra, & Westen, 2005), chronic PTSD can be persistent (e.g., Rothbaum et al., 1992 and Zlotnick et al., 1999) and resistant to treatment relative to other anxiety disorders (e.g., Foa, 2000). Clearly, more research is needed to fine-tune and improve the efficacy of CBT for PTSD.
Information processing theories (e.g., Foa and Kozak, 1986, Litz and Keane, 1989 and Mathews and MacLeod, 1994) provide one framework for hypothesis-driven, basic research with relevance for CBT clinicians. Most readers will be familiar with this conceptualization,1 which argues that traumatic memories are constructed of a network of information about the trauma, including cues (e.g., discrete physical cues and contextual reminders of the trauma), internal responses (e.g., emotional and physiological responses), and meaning-making elements (e.g., trauma-related beliefs or assumptions). These theories further propose that trauma memories are stored in an excessively fragmented, disorganized network, isolated from other information networks, relative to “normal” memories. Hypothetically, the atypical storage and retrieval of trauma memories may result in attentional problems, memory disruption, and intrusive thoughts (Brewin, 2001, Ehlers and Clark, 2000, Foa and Kozak, 1985, Foa and Riggs, 1993 and van der Kolk et al., 1994). Thus, the features of PTSD reviewed in this paper are believed to be a by-product of the unusual circumstances in which traumatic memories are formed and stored.
The basic and translational information processing literature has direct implications for the applied treatment setting. Theoretically, it is believed that approach-based treatment techniques assist in the habituation to the emotions (generally fear) associated with the trauma-related thoughts (Horowitz, 1986, Lang, 1977 and Rachman, 1971). From a behavioral perspective, a process of extinction learning is hypothesized to take place. Specifically, through approach of the trauma-related material, new learning occurs which specifies that this material (e.g., thoughts, emotions, and images related to the event) is not dangerous and that the fear reaction need not be activated when these reminders are encountered (see Keane, Zimering, & Caddell, 1985). From an information processing standpoint, the incorporation of new information into the trauma memory network (e.g., information that specifies when a particular trauma cue is no longer dangerous and does not need to be avoided), and the formation of new beliefs such as "this is only a memory and what happened is in the past and cannot harm me" are important to recovery (Foa, Steketee, & Rothbaum, 1989). Thus, the new learning often involves a cognitive element where the individual develops more adaptive ways of reacting to thoughts and feelings. However, for this process of habituation and/or new learning to take place, a trauma survivor must be willing to face feared stimuli, including trauma memories, rather than avoid feared stimuli.
In this paper, we review some recent findings from the basic, translational, and applied information processing literatures that have implications for CBT practice. In particular, exciting new research in the areas of attention, memory, intrusive thoughts, and thought suppression/acceptance may help clinicians to refine their practice for patients with PTSD.
