Article summary of Cognitive behavior therapies for posttraumatic stress disorder by Ehlers & Wild - 2021

What is emotional processing theory (EPT)?

Emotional processing theory (EPT) proposes a hypothetical sequence of fear-reducing changes that is evoked by emotional engagement with the memory of a significant event (the trauma). It is based around the concept of a fear structure. The fear structure is a type of mental framework for reaction to threat that includes information about a feared stimulus (e.g. a spider), physiological and behavioral responses (e.g. sweating, rapid heartbeat), and the meaning of the stimulus and response elements (e.g. the spider will bite me and I am afraid). The fear structure can be changed by activating it and presenting information that is incompatible with its elements that through prolonged exposure is integrated into the fear structure and replaces the pathological elements.

What is Ehlers and Clark´s (2000) cognitive model of PTSD?

The cognitive model of PTSD suggests that negative appraisals, disjointed trauma memories, and unhelpful coping strategies maintain PTSD.

• Patients with PTSD often have excessively negative meanings of the trauma that become more embedded over time. Perceived external threats can result from appraisals about impending danger (e.g. ¨I am not safe anywhere¨). Perceived internal threats often come from negative appraisals of one´s behavior, emotions, or reactions during the trauma (e.g. ¨I did nothing to stop it, it is my fault¨).
• Disjointed trauma memories refer to the subjectively worst moments of the trauma being excessively elaborated in memory and poorly integrated into the context of the trauma and previous and subsequent experiences. This induces a sense of threat similar to the one experienced during the trauma and causes the same feelings and emotions as though the trauma were occurring now rather than being a memory.
• Unhelpful coping strategies (e.g. excessive precautions, avoidance of reminders, rumination) prevent change in the negative appraisals and disjointed trauma memories and may increase symptoms.

Which six elements should effective trauma-focused psychological treatment have?

Effective trauma-focused psychological treatment should include:

• Psychoeducation about the nature and course of posttraumatic stress.
• Exposure either in vivo, through imaginal reliving, or narrative writing.
• Changing negative meanings of the trauma for the patient's view of themselves, other people, and the future.
• Dealing with a range of emotions that have different underlying beliefs that need to be identified and treated.
• Emotion regulation improvement, for example through breathing training.
• Changing memories by creating a coherent narrative of the trauma that helps the patient see the trauma in the context of other events in their lives.

What is imaginal reliving?

Patients visualize the traumatic event, usually with their eyes closed. They start with the first perception that something was wrong and end at a point when they were reasonably safe again. The patient describes moment by moment what is happening and what they are thinking and feeling. Imaginal reliving facilitates emotional engagement with the memory and gives access to details of the memory. The therapist supports the patient in maintaining awareness of the present surroundings.