Either way, assign your patients to review the written or recorded account 2 to 3 times per day between sessions. Repeating this exercise results in habituation to these memories, and the thoughts will evoke progressively less distress.
In vivo exposure is designed to extinguish the conditioned associations patients formed during the MVA. Travel-related anxiety is the primary focus of in vivo exposure because almost all patients experience it.11
This type of exposure therapy uses a fear hierarchy—a list of feared MVA reminders. Patients rate each reminder using a distress scale, such as the Subjective Units of Discomfort Scale (SUDS). Together the therapist and patient agree on a situation in the fear hierarchy that the patient feels able to confront in person without escaping. Patients confront the situation until their distress scale score declines by at least half, repeatedly addressing each item on the hierarchy until they have overcome the most frightening reminders. Consider recruiting patients’ family or friends to help complete these homework exercises.
Typically taught early in the course of cognitive-behavioral therapy, an anxiety management skill gives the patient an easy-to-use, effective way to reduce hyperarousal symptoms.
Anxiety management skills range from simple paced diaphragmatic breathing—where the patient learns to breathe from the abdomen, inhaling and exhaling to a count of 3—to more involved techniques, such as progressive muscle relaxation, when patients systemically tense and relax designated muscle groups in a sequential, articulated fashion.
The patient can use an anxiety management skill to lower basal physical arousal and acute arousal brought on by a stressful experience, such as confronting a reminder of the motor vehicle accident.
Cognitive therapy typically is conducted simultaneously with the other therapeutic components. Early in therapy, the clinician assesses patients’ beliefs related to the accident (such as “The world is very dangerous” or “I have no control over what happens on the road”) and their psychological experiences (“I will lose control of my emotions if I think about it”) and challenges the veracity of these assumptions by bringing up these distortions and statements as they occur within the treatment session. By using forms designed to identify thoughts and beliefs that produce anxiety, patients learn to monitor and challenge their maladaptive thoughts, in essence becoming their own cognitive therapists.
Scheduling pleasant events—assigning patients to participate in activities they previously enjoyed but have discontinued—has been used effectively to treat depression.19 For MVA survivors, this therapy is designed to target PTSD’s numbing symptoms by increasing patients’ social support and resilience.
Patients initially may need some cajoling, but once they begin pleasant activities they often find the experience reinforcing and mood-enhancing, which increases their future participation.
Although pharmacologic therapy for PTSD is beyond the scope of this article, antidepressants—including selective serotonin reuptake inhibitors (such as paroxetine and sertraline), tricyclics, and monoamine oxidase inhibitors—have been shown to effectively treat PTSD.20 For some patients, a combination of medication and psychotherapy may be best.
Patients with MVA-related PTSD often present other problems, including chronic pain, sleep problems, and generalized anxiety. How—and even if—to address these problems in therapy for PTSD is a matter of clinical judgment. Some evidence suggests that CBT can help improve comorbid conditions.7,21
Cognitive-behavioral therapy: What’s effective for MVA-related PTSD
|Symptom cluster||CBT component that targets it|
|Reexperiencing||In vivo and imaginal exposure|
|Avoidance||In vivo exposure (for MVA reminders) Imaginal exposure (for MVA memories and related affect)|
|Numbing||Pleasant events scheduling|
|Hyperarousal||Anxiety management skills training|
|All symptom clusters||Psychoeducation about PTSD|
|All symptom clusters||Cognitive therapy|
|Note: Although listed as targeting specific symptom clusters, CBT components have an effect across all clusters.|
|CBT: cognitive-behavior therapy; MVA: motor vehicle accident; PTSD: posttraumatic stress disorder|
|Source: Reference 11|
CASE CONTINUED: Getting back on the road
After 4 months of CBT, Mr. O’s symptoms have resolved to the point where he is able to drive and return to work. When confronted with situations that had been problematic, Mr. O uses the CBT tools he learned to monitor thoughts and reactions that previously led to distress. With each change and improvement he feels a growing sense of confidence.
- National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
- Hickling EJ, Blanchard EB. Overcoming the trauma of your motor vehicle accident: a cognitive behavioral treatment program, therapist guide. New York: Oxford University Press; 2006.
- Follette VM, Ruzek JI, Abueg FR. Cognitive-behavioral therapies for trauma, 2nd ed. New York: Guilford Press; 1998.
Drug brand names
- Paroxetine • Paxil
- Sertraline • Zoloft