DiscoverCounselor Toolbox PodcastCognitive Behavioral Interventions for PTSD
Cognitive Behavioral Interventions for PTSD

Cognitive Behavioral Interventions for PTSD

Update: 2019-07-314


411 -Cognitive Behavioral Interventions for PTSD

CEUs available at:

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.”









Cognitive Behavioral Interventions for PTSD

Cognitive Behavioral Interventions for PTSD

Charles Snipes