A critical review of negative affect and the application of CBT for PTSD

Brown, Wilson J.; Dewey, Daniel; Bunnell, Brian E.; Boyd, Stephen J.; Wilkerson, Allison K.; Mitchell, Melissa A.; Bruce, Steven E.

doi:10.1177/1524838016650188

Cited by 43Posttraumatic Stress Disorder ResearchAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychotherapy Techniques and Applications

A critical review of negative affect and the application of CBT for PTSD

Brown, Wilson J., Dewey, Daniel, Bunnell, Brian E., Boyd, Stephen J., Wilkerson, Allison K., Mitchell, Melissa A., Bruce, Steven E.·2018·Trauma, Violence, & Abuse

DOI 10.1177/1524838016650188

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Abstract

Forms of cognitive and behavioral therapies (CBTs), including prolonged exposure and cognitive processing therapy, have been empirically validated as efficacious treatments for posttraumatic stress disorder (PTSD). However, the assumption that PTSD develops from dysregulated fear circuitry possesses limitations that detract from the potential efficacy of CBT approaches. An analysis of these limitations may provide insight into improvements to the CBT approach to PTSD, beginning with an examination of negative affect as an essential component to the conceptualization of PTSD and a barrier to the implementation of CBT for PTSD. As such, the literature regarding the impact of negative affect on aspects of cognition (i.e., attention, processing, memory, and emotion regulation) necessary for the successful application of CBT was systematically reviewed. Several literature databases were explored (e.g., PsychINFO and PubMed), resulting in 25 articles that met criteria for inclusion. Results of the review indicated that high negative affect generally disrupts cognitive processes, resulting in a narrowed focus on stimuli of a negative valence, increased rumination of negative autobiographical memories, inflexible preservation of initial information, difficulty considering counterfactuals, reliance on emotional reasoning, and misinterpretation of neutral or ambiguous events as negative, among others. With the aim to improve treatment efficacy of CBT for PTSD, suggestions to incorporate negative affect into research and clinical contexts are discussed.

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From Clinical Efficacy of Psychotherapeutic Interventions for Post-Traumatic Stress Disorder in Children and Adolescents: A Systematic Review and Analysis. (2024) · cites this paper as [65]

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“There is a substantial body of neuroscience literature that evinces the impact of dysregulated fear circuitry within the development of PTSD (Garfinkel & Liberzon, 2009; Johnson, McGuire, Lazarus, &Palmer, 2012; VanElzakker, Dahlgren, Davis, Dubois, & Shin, 2014).”
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The protective effects of brief mindfulness meditation training
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Risk factors predict post-traumatic stress disorder differently in men and women
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Negative affect improves the quality of memories: Trading capacity for precision in sensory and working memory.
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Learning Models of PTSD
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Current positive and negative affective states modulate attention: An attentional blink study
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Negative affect promotes encoding of and memory for details at the expense of the gist: Affect, encoding, and false memories
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Mindfulness-Based Attention as a Moderator of the Relationship Between Depressive Affect and Negative Cognitions
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“Indeed, mindfulness has been a technique that has shown promise in reducing negative affect by increasing tolerance to distorted cognitions (Gilbert & Christopher, 2010; Shallcross, Troy, Boland, & Mauss, 2010).”
Dispositional affect predicts temporal attention costs in the attentional blink paradigm
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Time-course of attention to negative stimuli: Negative affectivity, anxiety, or dysphoria?
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Affective Dispositions and PTSD Symptom Clusters in Female Interpersonal Trauma Survivors
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Type D personality and posttraumatic stress disorder in victims of violence: a cross‐sectional exploration
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Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review
Burback, L., Brémault‐Phillips, S., Nijdam, M. J., McFARLANE, A. C., & Vermetten, E. H. G. J. M. (2023) · Current Neuropharmacology · doi:10.2174/1570159x21666230428091433 · Cited by 232 · see citing works
Virtual Reality and Transcranial Direct Current Stimulation for Posttraumatic Stress Disorder
Wout‐Frank, M. V. ‘., Arulpragasam, A. R., Faucher, C. R., Aiken, E., Shea, M. T., Jones, R. N., Greenberg, B. D., & Philip, N. S. (2024) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2023.5661 · Cited by 61 · see citing works
Emotion Dysregulation Predicts Dropout from Prolonged Exposure Treatment among Women Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder
Gilmore, A. K., López, C. M., Muzzy, W. A., Brown, W. J., Grubaugh, A. L., Oesterle, D. W., & Acierno, R. E. (2020) · Women s Health Issues · doi:10.1016/j.whi.2020.07.004 · Cited by 42 · see citing works
Agency via Life Satisfaction as a Protective Factor From Cumulative Trauma and Emotional Distress Among Bedouin Children in Palestine
Veronese, G., Pepe, A., Cavazzoni, F., Obaid, H., & Viejo, J. M. P. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.01674 · Cited by 37 · see citing works
“The addition of negative affect was in keeping with current theoretical frameworks that associate specific negative emotions and DSM-5 criteria for PTSD (Brown et al., 2016; Badour et al., 2017), positing that negative emotions play a key role in trauma and should therefore be taken into account in trauma research, an…”
BackgroundResultInfluential
Clinical Efficacy of Psychotherapeutic Interventions for Post-Traumatic Stress Disorder in Children and Adolescents: A Systematic Review and Analysis.
Gkintoni, E., Kourkoutas, E., Yotsidi, V., Stavrou, P. D., & Prinianaki, D. (2024) · Children · doi:10.3390/children11050579 · Cited by 37 · see citing works
“CBT for PTSD is more effective than treatment as usual or unstructured therapy modalities, according to empirical data [65], producing clinically significant outcomes.”
Method
The influence of risk perception for COVID-19 pandemic on posttraumatic stress disorder in healthcare workers: A survey from four designated hospitals
Geng, S., Zhou, Y., Zhang, W., Lou, A., Cai, Y., Xie, J., Sun, J., Zhou, W., Liu, W., & Li, X. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2564 · Cited by 35 · see citing works
“, ‘Now the world is even more dangerous’) towards COVID-19 pandemic and elevated their risk perceptions (Brown et al., 2018).”
Background
Rumination Mediates the Relationship Between Negative Affect and Posttraumatic Stress Disorder Symptoms in Female Interpersonal Trauma Survivors
Brown, W. J., Hetzel‐Riggin, M. D., Mitchell, M. A., & Bruce, S. E. (2018) · Journal of Interpersonal Violence · doi:10.1177/0886260518818434 · Cited by 34 · see citing works
Efficacy of interpersonal psychotherapy for post-traumatic stress disorder: A systematic review and meta-analysis
Althobaiti, S., Kazantzis, N., Ofori‐Asenso, R., Romero, L., Fisher, J., Mills, K. E., & Liew, D. (2019) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.12.021 · Cited by 32 · see citing works
Posttraumatic stress symptoms, posttraumatic growth, and personality factors: A network analysis
Graziano, R. C., Brown, W. J., Strasshofer, D. R., Yetter, M. A., Berfield, J. B., Haven, S. E., & Bruce, S. E. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.06.011 · Cited by 21 · see citing works
The incorporation of emotion-regulation skills into couple- and family-based treatments for post-traumatic stress disorder
PERLICK, D. A., Sautter, F. J., Becker‐Cretu, J. J., Schultz, D., Grier, S., Libin, A., Schladen, M. M., & Glynn, S. M. (2017) · Military Medical Research · doi:10.1186/s40779-017-0130-9 · Cited by 20 · see citing works
“In support of this thesis, a recent review of the role of negative affect in the development of PTSD across multiple trauma populations argued that negative affect disrupts the cognitive processes that are needed to participate in cognitive behavioral therapies fully and recommended ways to incorporate regulating nega…”
Background
Residual Symptoms of Posttraumatic Stress Disorder and Alcohol Use Disorder Following Integrated Exposure Treatment Versus Coping Skills Treatment
Tripp, J. C., Angkaw, A. C., Schnurr, P. P., Trim, R. S., Haller, M. M., Davis, B. C., & Norman, S. B. (2020) · Journal of Traumatic Stress · doi:10.1002/jts.22552 · Cited by 12 · see citing works
Effects of Emotion Dysregulation on Post-treatment Post-traumatic Stress Disorder and Depressive Symptoms Among Women Veterans With Military Sexual Trauma
López, C. M., Gilmore, A. K., Brown, W. J., Hahn, C. K., Muzzy, W. A., Grubaugh, A. L., & Acierno, R. E. (2021) · Journal of Interpersonal Violence · doi:10.1177/08862605211005134 · Cited by 10 · see citing works
“…of PE, emotion regulation difficulties may represent a challenge to implementing the prescribed techniques of PE given that the techniques require self-regulatory and cognitive preconditions that may be disrupted by difficulties with emotion regulation (see Brown et al., 2018, for a review).”
Background
Emotions, coping and psychological flexibility in earthquake survivors: a cross-sectional study
Turan, N., Hülya, K. E., & Acar Gül, G. B. (2025) · Psychology, Health & Medicine · doi:10.1080/13548506.2024.2433540 · Cited by 9 · see citing works
“…negative affect may often impair cognitive processes, resulting in increased repetition of negative memories, inflexible retention of initial information, difficulty evaluating counterfactuals, reliance on emotional reasoning, or negative mis-interpretation of ambiguous events (Brown et al., 2018).”
Application of the Unified Protocol for a Japanese Patient with Post-Traumatic Stress Disorder and Multiple Comorbidities: A Single-Case Study
Kato, N., Ito, M., Matsuoka, Y., Horikoshi, M., & Ono, Y. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182111644 · Cited by 7 · see citing works
“These results in those studies are also consistent with the suggestion that applying a transdiagnostic protocol for negative affect in PTSD might not address the dysregulated fear circuitry that is the focus of current CBT treatment approaches [25].”
BackgroundResult
Transcutaneous vagal nerve stimulation for the treatment of trauma- and stressor-related disorders: systematic review of randomised controlled studies
Benzouak, T., Danyluck, C. M., Gunpat, S., Amougou, S. E., Hamoudeh, R. A., Prudencio-Brunello, M. A., Nachabe, J., Edwin, F., Kisely, S. R., & Rao, S. (2025) · BJPsych Open · doi:10.1192/bjo.2025.10057 · Cited by 5 · see citing works
Psychological adjustment of siblings of children with Prader-Willi syndrome
Murphy, L. B., Thornton, J., & Thornton, E. (2022) · Journal of Intellectual & Developmental Disability · doi:10.3109/13668250.2022.2132630 · Cited by 5 · see citing works
“…further describe that higher levels of negative affect are associated with more negative outcomes in individuals with PTSD. High levels of negative affect can disrupt cognition, increase rumination of negative autobiographical memories, and direct attention to negative events (Brown et al., 2016).”
Background
The Role of Negative Affect in the Assessment of Quality of Life among Women with Type 1 Diabetes Mellitus
Gawlik, N. R., & Bond, M. J. (2018) · Diabetes & Metabolism Journal · doi:10.4093/dmj.2018.42.2.130 · Cited by 4 · see citing works
“Negative affect may manifest in a number of forms, including all of behavioral (functional impairment), affective (rumination on current negative circumstances), and cognitive processes [5].”
Background
The Relationship Between a Hierarchical Transdiagnostic Model of Vulnerability Factors and Posttraumatic Stress Disorder Symptom Clusters
Kreminski, M. A., Courtney, J. A., Drummond, S. P. A., & Norton, P. J. (2021) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-021-09939-3 · Cited by 3 · see citing works
Implementation and Effects of the Broad-Minded Affective Coping (BMAC) Technique: a Pilot Study
Miguel-Álvaro, A., Gómez, M. L. N., Hornillos, C., Hernández-Lloreda, M. J., & Crespo, M. (2023) · International Journal of Cognitive Therapy · doi:10.1007/s41811-023-00163-3 · Cited by 3 · see citing works
“Research has primarily focused on autobiographical memory of events with negative emotional valence and its relation to various psychopathological conditions (Brown et al., 2016).”
Background
The Influence of Transdiagnostic Vulnerability Factors on PTSD Symptom Clusters in a Veteran Sample
Kreminski, M. A., Courtney, J. A., Drummond, S. P. A., & Norton, P. J. (2023) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674221103488 · Cited by 2 · see citing works
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“…Hussong, Hicks, Levy, & Curran, 2001; Whiteman, Fowkes, Deary, & Lee, 1997; Calhoun et al., 2001) and posttraumatic stress disorder (PTSD) alone (Brown et al., 2016; Christiansen & Elklit, 2008; FerrierAuerbach, Erbes, Polusny, Rath, & Sponheim, 2010; Frazier et al., 2011; James et al., 2015;…”
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A Review of the Role of Negative Cognitions About Oneself, Others, and the World in the Treatment of PTSD
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Authors: Brown, W. J., Dewey, D., Bunnell, B. E., Boyd, S. J., Wilkerson, A. K., Mitchell, M. A., & Bruce, S. E.
Affiliations: Summa Health System (US)
Medical University of South Carolina (US)
VA Portland Health Care System (US)
University of Missouri–St. Louis (US)
Corresponding author: Brown, Wilson J.
ORCID: Brown, Wilson J.
Bunnell, Brian E.
Wilkerson, Allison K.
Bruce, Steven E.
Venue: Trauma, Violence, & Abuse
Publisher: SAGE Publications
Published: 2016-06-14
Volume: 19
Issue: 2
Pages: 176-194
ISSN: 1524-8380 (ISSN-L)
1552-8324
DOI: 10.1177/1524838016650188
OpenAlex: W2437141769
Cited by: 43
References: 159
Citations by year: 2026: 6 · 2025: 8 · 2024: 9 · 2023: 4 · 2022: 3 · 2021: 4 · 2020: 2 · 2019: 2 · 2018: 3 · 2017: 1 · 2016: 1
FWCI: 3.13
Type: journal article
Language: en
Open access: closed
Licence: journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations: Trauma Violence & Abuse (publishedVersion, public-domain)
PubMed (publishedVersion)
Topics: Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords: negative affect, post-traumatic stress disorder, cognitive behavioral therapy, prolonged exposure, cognitive processing therapy, fear circuitry, rumination, autobiographical memory, emotion regulation, attention, counterfactual reasoning, emotional reasoning, treatment efficacy
MeSH terms: Fear, Female, Humans, Irritable Mood, Male, Stress Disorders, Post-Traumatic, Cognitive Behavioral Therapy, Treatment Outcome

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A critical review of negative affect and the application of CBT for PTSD

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