4.4- Posttraumatic Stress Disorder

Case 4 - Treatment Goals and Planning: (pp. 51-60)

Answer: C. She was sexually assaulted by an acquaintance and developed re-experiencing, avoidance, and hyperarousal symptoms

Explanation: Cindy’s case involves a traumatic sexual assault (meeting Criterion A), followed years later by intrusive recollections, avoidance, and hyperarousal. DSM-5 requires exposure to a traumatic event + specific clusters of symptoms. Options A & B involve stressors that do not meet Criterion A.

PTSD Diagnosis

Which of the following best reflects why Cindy’s experience met DSM-5 criteria for PTSD?

A. She experienced daily stressors and poor academic performance
B. She witnessed violence on television, leading to intrusive dreams
C. She was sexually assaulted by an acquaintance and developed re-experiencing, avoidance, and hyperarousal symptoms
D. She reported generalized anxiety unrelated to trauma

Answer: B. CPT emphasizes cognitive restructuring and trauma-related beliefs, with written accounts of the trauma, while PE focuses on repeated imaginal and in vivo exposure

Explanation: CPT combines written narrative exposure with restructuring of maladaptive trauma-related beliefs. PE emphasizes repeated prolonged exposure to trauma memories and cues. Both are effective but differ in therapeutic focus.

Treatment Approach

Cindy received Cognitive Processing Therapy (CPT). Which of the following BEST distinguishes CPT from Prolonged Exposure (PE)?

A. CPT focuses exclusively on medication management
B. CPT emphasizes cognitive restructuring and trauma-related beliefs, with written accounts of the trauma, while PE focuses on repeated imaginal and in vivo exposure
C. CPT avoids any exposure component, while PE relies on relaxation training
D. CPT and PE are identical except for session length

Answer: B. Exposure to new stressors or losses that triggered unresolved trauma memories

Explanation: Delayed-onset PTSD can occur when new stressors or life transitions reactivate unresolved trauma. Research shows that reminders or cumulative stress can precipitate symptoms long after the original trauma. Option D is incorrect; DSM-5 recognizes delayed expression.

Delayed Onset of PTSD

Cindy developed clear PTSD symptoms 10 years after the assault. Which of the following factors might explain such delayed onset?

A. Protective family relationships preventing symptoms from surfacing
B. Exposure to new stressors or losses that triggered unresolved trauma memories
C. A misdiagnosis of depression instead of PTSD
D. PTSD cannot emerge more than 6 months after trauma

Answer: B. Cognitive restructuring

Explanation: Restructuring faulty cognitions (e.g., self-blame, guilt) is central to CPT. Cindy’s work on self-blame directly reduced guilt and depression.

Cognitive Distortions

During therapy, Cindy challenged her belief “It was my fault.” This is an example of:

A. Behavioral activation
B. Cognitive restructuring
C. Systematic desensitization
D. Psychoeducation only

Answer: C. 53%

Explanation: In the large randomized trial, 53% of women treated with CPT no longer had PTSD, compared to only 2.2% in the minimal attention condition.

Research Findings

In Resick et al. (2002), what percentage of rape survivors receiving CPT no longer met criteria for PTSD at posttreatment?

A. 2.2%
B. 25%
C. 53%
D. 75%

Answer: A. Predisposing: previous trauma exposure; Precipitating: acquaintance rape; Perpetuating: avoidance, self-blame, substance use; Protective: motivation for therapy, supportive relationships

Explanation: Cindy’s case fits the 4Ps well: predisposing vulnerabilities (earlier stressors, possible cognitive style), precipitating trauma (rape), perpetuating factors (avoidance, guilt, substance misuse), and protective factors (engagement in therapy, eventual supportive relationships).

Case Formulation (4Ps)

Which of the following correctly applies the 4Ps of case formulation to Cindy?

A. Predisposing: previous trauma exposure; Precipitating: acquaintance rape; Perpetuating: avoidance, self-blame, substance use; Protective: motivation for therapy, supportive relationships
B. Predisposing: stable self-esteem; Precipitating: successful treatment; Perpetuating: peer support; Protective: substance misuse
C. Predisposing: healthy coping skills; Precipitating: cognitive therapy; Perpetuating: treatment dropout; Protective: none
D. Predisposing: substance use; Precipitating: therapy attendance; Perpetuating: guilt reduction; Protective: absence of family support

Answer: C. Accidentally running over a family pet

Explanation: DSM-5 requires exposure to actual or threatened death, serious injury, or sexual violence. While distressing, losing a pet does not typically qualify. Options A, B, and D do.

Thinking Critically — PTSD Criteria

Which of the following events would clearly NOT meet Criterion A for PTSD in DSM-5?

A. Sexual assault by an acquaintance
B. Combat exposure
C. Accidentally running over a family pet
D. Surviving a natural disaster

Answer: C. Accidentally running over a pet with the car

Explanation: DSM-5 limits Criterion A to exposure to death, threatened death, serious injury, or sexual violence. A pet’s death is distressing but not sufficient.

Criterion A (Trauma Exposure)

Which of the following events would NOT meet Criterion A for PTSD according to DSM-5?

A. Experiencing a sexual assault
B. Witnessing a close friend’s violent death
C. Accidentally running over a pet with the car
D. Surviving a natural disaster

Answer: B. Expanded diagnostic coverage, with potential legal and insurance implications

Explanation: Broadening criteria may inflate prevalence rates and complicate legal/insurance claims, blurring boundaries between trauma-related and general stress disorders.

Diagnostic Boundaries

Relaxing PTSD criteria to include less extreme stressors (e.g., watching disturbing news footage) could result in:

A. More accurate diagnosis without consequences
B. Expanded diagnostic coverage, with potential legal and insurance implications
C. Elimination of comorbidity with depression
D. Reduced recognition of combat-related PTSD

Answer: C. It facilitates habituation and cognitive reprocessing of trauma memories

Explanation: Prolonged or written exposure allows emotional processing and reduces avoidance, a core maintaining factor in PTSD.

Role of Exposure

In cognitive-behavioral treatment for PTSD, why is repeated exposure emphasized?

A. It increases physiological arousal to maintain symptom vigilance
B. It helps patients avoid distressing memories
C. It facilitates habituation and cognitive reprocessing of trauma memories
D. It serves only as a relaxation strategy

Answer: B. Some patients improve with cognitive restructuring or stress inoculation training, without direct confrontation of trauma memories

Explanation: Some treatments (e.g., SIT, CPT) include less intense exposure or emphasize skills and beliefs, yet still reduce PTSD symptoms.

Alternatives to Exposure

Which of the following BEST reflects an argument against requiring prolonged exposure in PTSD treatment?

A. PTSD cannot be treated with any psychotherapy
B. Some patients improve with cognitive restructuring or stress inoculation training, without direct confrontation of trauma memories
C. Avoidance must be reinforced for recovery
D. Exposure always worsens outcomes long-term

Answer: B. Prolonged exposure was superior long-term compared to stress inoculation training

Explanation: SIT worked better immediately post-treatment, but PE showed superior long-term benefits. Both were more effective than control conditions.

Treatment Efficacy (CPT vs. PE vs. SIT)
Foa et al. (1991) found that:

A. Stress inoculation training was more effective than prolonged exposure at 3.5-month follow-up
B. Prolonged exposure was superior long-term compared to stress inoculation training
C. Supportive therapy outperformed both PE and SIT
D. Both PE and SIT were no better than waitlist

Answer: B. It emphasizes written accounts and cognitive restructuring of maladaptive trauma-related beliefs

Explanation: CPT incorporates exposure through written narratives but focuses strongly on addressing faulty cognitions like guilt and self-blame.

CPT Components

What distinguishes Cognitive Processing Therapy (CPT) from other exposure-based therapies?

A. It avoids trauma discussion altogether
B. It emphasizes written accounts and cognitive restructuring of maladaptive trauma-related beliefs
C. It uses only pharmacological interventions
D. It exclusively teaches relaxation and breathing

Answer: B. New stressors or life events triggered unresolved trauma memories

Explanation: DSM-5 allows “delayed expression” PTSD. New stressors often reactivate suppressed or partially processed trauma.

Delayed PTSD

Cindy’s symptoms emerged 10 years after her assault. Which of the following is the MOST plausible explanation?

A. PTSD cannot emerge after 6 months
B. New stressors or life events triggered unresolved trauma memories
C. She had no trauma history, so PTSD was misdiagnosed
D. Symptoms were faked for secondary gain

Answer: A. Trauma can be forgotten entirely and later recalled

Explanation: Some theorists argue memories can be repressed and later retrieved, though this remains controversial in clinical and legal contexts.

Repressed Memories

The debate over repressed and recovered memories centers on whether:

A. Trauma can be forgotten entirely and later recalled
B. Memory of trauma is always accurate and permanent
C. Only combat trauma can be repressed
D. Memory recall is irrelevant to PTSD diagnosis

Answer: C. Genetic vulnerability to anxiety

Explanation: Protective factors include social support and adaptive coping. Genetic vulnerability may predispose someone to difficulties rather than protect them.

Non-PTSD Outcomes

Many trauma-exposed individuals never develop PTSD. Which of the following factors is LEAST likely to promote resilience?

A. Supportive social environment
B. Strong coping skills and problem-solving abilities
C. Genetic vulnerability to anxiety
D. Adaptive cognitive styles (e.g., optimism)

Answer: B. Engagement in therapy and willingness to challenge self-blame

Explanation: Cindy’s therapeutic engagement and cognitive restructuring of guilt were protective factors that supported her recovery.

Protective Factors in Cindy’s Case

Which of the following was a key protective factor aiding Cindy’s recovery?

A. Continued avoidance of trauma cues
B. Engagement in therapy and willingness to challenge self-blame
C. Ongoing substance misuse
D. Lack of social support

Answer: C. 31%

Explanation: National survey data showed about one-third of rape survivors met PTSD criteria.

Prevalence of PTSD after Rape (Kilpatrick et al., 1992)

What proportion of rape victims develop PTSD at some point after assault?

A. 5%
B. 15%
C. 31%
D. 50%

Answer: C. 15%

Explanation: About 15% of male veterans and 9% of female veterans in the Vietnam theater met PTSD criteria.

Vietnam Veterans (Kulka et al., 1990)

According to the National Vietnam Veterans Readjustment Study, what percentage of male theater veterans met PTSD criteria at evaluation (6-month prevalence)?

A. 5%
B. 9%
C. 15%
D. 31%

Answer: B. Substance use problems, depression, and sexual dysfunctions

Explanation: Depression, substance misuse, suicidality, and sexual dysfunction are frequent sequelae of sexual assault.

Comorbidity in Rape Survivors

Which of the following comorbidities is MOST common among sexual assault survivors?

A. Schizophrenia
B. Substance use problems, depression, and sexual dysfunctions
C. Bipolar disorder
D. Autism spectrum disorder

Answer: C. 19.2%

Explanation: About 19.2% of rape victims reported suicide attempts versus 2.2% of non-victims; another 44% reported suicidal thoughts.

Suicide Risk (Kilpatrick et al., 1985)

Compared to non-victims, what percentage of rape survivors reported suicide attempts?

A. 2.2%
B. 10%
C. 19.2%
D. 44%

Answer: B. Avoidance, self-blame, and substance misuse

Explanation: Perpetuating factors are those maintaining symptoms: avoidance of trauma cues, self-blame, and substance misuse.

Cindy’s Case Formulation

Which of the following BEST illustrates the perpetuating factors in Cindy’s case?

A. Her traumatic rape experience
B. Avoidance, self-blame, and substance misuse
C. Engagement in therapy and social support
D. Pre-existing vulnerability from childhood stress

Answer: B. Symptoms of avoidance

Explanation: Avoidance is a core perpetuating factor in PTSD. Both tardiness and substance use were framed as avoidance strategies, not grounds to terminate treatment.

During Cindy’s early sessions, her therapist identified her late arrival and marijuana use as:

A. Symptoms of depression
B. Symptoms of avoidance
C. Signs of noncompliance that should end treatment
D. Evidence of relapse

Answer: B. That she was not responsible and could let go of shame

Explanation: Cindy wrote she would not let the rape destroy her, she was not responsible, and she had nothing to be ashamed of.

Cindy’s final written reframe emphasized:

A. That she was permanently damaged but could cope with it
B. That she was not responsible and could let go of shame
C. That she would confront Mark soon to find closure
D. That her family was to blame for her suffering

Answer: C. No longer meeting PTSD, depression, or marijuana abuse criteria

Explanation: At post-treatment and follow-ups, Cindy was within the non-symptomatic range for PTSD, depression, and marijuana abuse.

Post-treatment evaluations showed Cindy’s outcome was:

A. Partial recovery with persistent depression
B. Symptom remission but ongoing marijuana use
C. No longer meeting PTSD, depression, or marijuana abuse criteria
D. Still meeting full PTSD criteria but reduced avoidance

Answer: C. 6.8%

Explanation: Current = 3.5%, lifetime = 6.8% (Kessler et al., 2005).

According to the National Comorbidity Survey Replication, lifetime prevalence of PTSD is about:

A. 2%
B. 3.5%
C. 6.8%
D. 15%

Answer: C. 39%

Explanation: 13% of women reported completed rape, and of these, 39% had been raped more than once.

In Kilpatrick et al. (1992), what proportion of women reported being raped more than once?

A. 13%
B. 31%
C. 39%
D. 77%

Answer: D. 77.6%

Explanation: Koss et al. (1987), Muehlenhard & Linton (1987) found rates up to 77.6%.

Studies of female college students revealed prevalence of some form of sexual aggression in dating situations as high as:

A. 13%
B. 31%
C. 44%
D. 77.6%

Answer: B. 15% males, 9% females

Explanation: About 15% of male and 9% of female veterans met PTSD criteria.

Vietnam veteran PTSD prevalence (Kulka et al., 1990) was:

A. 5% males, 3% females
B. 15% males, 9% females
C. 20% males, 12% females
D. 31% males, 19% females

Answer: B. 7.8%

Explanation: 7.8% of female veterans met “partial PTSD” criteria.

Partial PTSD prevalence among female Vietnam theater veterans was:

A. 1.1%
B. 7.8%
C. 9%
D. 15%

Answer: C. 15–20%

Explanation: Taylor & Koch (1995) reported 15–20%.

PTSD prevalence following severe car accidents has been found to be:

A. 1–5%
B. 10–15%
C. 15–20%
D. 25–30%

Answer: C. 19.2%

Explanation: 19.2% attempted suicide, compared to 2.2% in non-victims.

Kilpatrick et al. (1985) found that what percentage of rape victims had attempted suicide?

A. 2.2%
B. 13%
C. 19.2%
D. 44%

Answer: B. Depression, substance abuse, and other anxiety disorders

Explanation: High rates of depression, substance abuse, and anxiety disorders were observed.

Vietnam veterans with PTSD frequently showed comorbid:

A. Schizophrenia and bipolar disorder
B. Depression, substance abuse, and other anxiety disorders
C. Obsessive-compulsive disorder and eating disorders
D. Personality disorders and psychosis

Answer: B. More effective than prolonged exposure immediately post-treatment

Explanation: SIT was more effective immediately, but prolonged exposure showed greater long-term benefits.

Foa et al. (1991) found that stress inoculation training (SIT) was:

A. Less effective than prolonged exposure immediately post-treatment
B. More effective than prolonged exposure immediately post-treatment
C. Ineffective compared to supportive therapy
D. Superior long-term compared to prolonged exposure

Answer: B. More effective than a waiting list

Explanation: Imaginal exposure was superior to waiting list controls.

Keane et al. (1989) found that prolonged imaginal exposure was:

A. Less effective than a waiting list
B. More effective than a waiting list
C. No different from supportive therapy
D. Only effective in females

Answer: C. 53%

Explanation: 53% in the CPT group vs. 2.2% minimal attention.

In Resick et al. (2002), what percentage of rape victims no longer had PTSD after CPT?

A. 2.2%
B. 40%
C. 53%
D. 77%

Answer: B. Gains persisted 5–10 years

Explanation: Improvements were maintained over 5–10 years.

Long-term follow-up of CPT (Resick et al., 2012) showed:

A. Gains faded within 1 year
B. Gains persisted 5–10 years
C. Only partial improvement remained
D. Depression worsened after 5 years

Answer: C. 40%

Explanation: About 40% of veterans no longer met PTSD criteria after CPT.

Monson et al. (2007) found that CPT adapted for veterans led to how many no longer meeting PTSD criteria post-treatment?

A. 15%
B. 25%
C. 40%
D. 53%

Answer: B. Family history of trauma (father with PTSD)

Explanation: Family trauma history and limited support were predisposing vulnerabilities.

(Predisposing) Which factor best fits as a predisposing vulnerability in Cindy’s case?

A. Being raped by an acquaintance
B. Family history of trauma (father with PTSD)
C. Using marijuana before sessions
D. Avoiding watching the news

Answer: B. The series of rapes by Mark

Explanation: The rapes directly triggered PTSD symptoms.

(Precipitating) Which event precipitated Cindy’s PTSD?

A. Strained relationship with her brother
B. The series of rapes by Mark
C. Marijuana use
D. Watching violent news footage

Answer: D. Perpetuating factors

Explanation: They maintained her symptoms by blocking recovery.

(Perpetuating) Cindy’s avoidance behaviors (lateness, marijuana use) are examples of:

A. Protective factors
B. Predisposing factors
C. Precipitating factors
D. Perpetuating factors

Answer: B. The support of her therapist and husband

Explanation: Social support and therapeutic alliance helped recovery.

(Protective) Which of the following was a protective factor aiding Cindy’s recovery?

A. Distrust of authority figures
B. The support of her therapist and husband
C. Substance use before sessions
D. Keeping secrets from family