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Psychological theories of posttraumatic stress disorder.
Brewin, C.R., & Holmes, E.A. (2003)
Clinical Psychology Review, 23, 339-376
Memory and PTSD
In PTSD, there are a number of changes in memory functioning that are comparable with depressed patients: 1) a bias toward enhanced recall of trauma-related material 2) difficulties in retrieving autobiographical memories of specific incidents.
Specific changes in memory of PTSD are: 1) a contradictory patterns of recall related to the traumatic material itself. High levels of emotions are in some studies associated with more vivid and long-lasting memories, but in others with vague memories, lacking in detail and error prone. PTSD is described as characterized by both high-frequency, distressing, intrusive memories and by amnesia for the details of the event. 2) the reliving of memories, or flashbacks to the trauma. Flashbacks are dominated by sensory detail. These images and sensations are typically disjointed and fragmentary. Reliving is reflected in a distortion in the sense of time, such that the traumatic event seems to be happening in the present rather than belonging in the past. Reliving episodes are triggered involuntarily by specific reminders that relate in some way to the circumstances of the trauma.
Flashbacks are a distinctive feature of PTSD.
Individual differences in working memory capacity appear to be related to the ability to prevent unwanted material from intruding and negatively affecting task performance.
Attention and PTSD
Research does not provide evidence that the effects of an attentional bias are unique to PTSD.
Dissociation and PTSD
Dissociation are any kind of temporary breakdown in what we think of as the relatively continuous, interrelated processes of perceiving the world around us, remembering the past, or having a single identify that links our past with our future.
Mild dissociative reactions are common under stress.
Dissociative symptoms most commonly encountered in trauma include: emotional numbing, derealisation, depersonalisation, out-of-body experiences. They are related to the severity of the trauma, fear of death, and feeling helpless.
It has been suggested that such reactions reflect a defensive response related to freezing in animals.
When these symptoms occur in the course of a traumatic experience, they are referred to as ‘peri-traumatic dissociation’.
The presence of dissociative symptoms occurring after rather than during trauma is not consistently associated with risk for later PTSD.
Cognitive-affective reactions and PTSD
A requirement of the PTSD diagnosis according to the DSM-IV, is to experience intense fear, helplessness, or horror at the time of the trauma.
There is a strong relationship between each of the specific reactions in victims of violent crime and the risk of PTSD.
Mental defeat is the perceived loss of all autonomy, a state of giving up in one’s mind all efforts to retain one’s identity as a human being with a will of one’s own. It goes beyond helplessness in attacking the person’s very identity.
Some emotions are the direct result of outcomes, others depend on an element of cognitive appraisal. Posttrauma, cognitive appraisal of the cause of, responsibility for, and future implications of the trauma will provide numerous opportunities to generate negative emotions.
Feelings of guilt, shame, sadness, betrayal, humiliation, and anger frequently accompany PTSD.
High levels of anger (specifically with others) predict a slower recovery from PTSD. Shame is a predictor of how PTSD symptoms develop over time.
Beliefs and PTSD
The subjective perception of threat is an influential predictor of distress and failure to respond to treatment. Traumatic events shatter people’s basic beliefs and assumptions.
A general increase in negative beliefs about the self, others, and the world has been found in trauma victims with PTSD.
Trauma has the potential to destroy trust and lead to the belief in victims that they have been let down or betrayed.
High levels of anger with others reported by PTSD patients are consistent with a loss of belief in the good intentions of other people.
PTSD is associated with the belief that trauma has brought about a negative and permanent change in the self and in the likelihood of achieving life goals.
Negative interpretations of symptoms predicted a slower recovery from PTSD. Negative beliefs do not have to occur during the trauma itself, but may represent the outcome of a separate appraisal process that only begins after the danger is past.
If beliefs occurred peri-traumatically, they could form part of the re-experienced trauma memory and thus be triggered by reminders of the trauma.
Cognitive coping strategies and PTSD
Attempts to suppress unwanted thoughts are usually doomed to failure. Afterwards, the thoughts return even more strongly.
Avoidance and thought suppression are related to a slower recovery from PTSD.
Coping strategies associated with greater risk of PTSD include: rumination and increased use of safety behaviours.
Social support and PTSD
A negative social environment is a good indicator of PTSD symptomatology. Negative appraisal of others’ support attempts predicts PTSD.
Negative social support is a stronger predictor for PTSD in women.
Stress response theory
Horowitz argued that when faced with trauma, people’s initial response is to outcry at the realisation of the trauma. A second response is to try to assimilate the new trauma information with prior knowledge. At this point, many individuals experience a period of information overload during which they are unable to match their thoughts and memories of the trauma with the way that they represented meaning before the trauma. In response to this tension, psychological defence mechanisms are brought into play to avoid memories of the trauma pace the extent to which it is recalled. The fundamental psychological need to reconcile new and old information means that trauma memories will actively break into consciousness in the form of intrusions, flashbacks, and nightmares. These consciously experienced trauma memories provide the individuals with an opportunity to try to reconcile them with pretrauma representations.
According to Horowitz, two opposing processes are at work: 1) one to defend the individual by the suppression of trauma information 2) one to promote the working through of the traumatic material by bringing it to mind.
The individual oscillates between avoidance and intrusions of the trauma. This allows the traumatic information to be worked through, and as this happens, the intensity of each phase decreases. Longer term structures in memory representing the self or future goals can be adjusted so that they are consistent with the new data, at which point, the trauma processing is considered to be completed. Failure to process the trauma information is proposed to lead to persistent posttraumatic reactions as the information remains in active memory and continues to intrude and be avoided.
Areas not treated in this theory are: the difference between flashbacks and ordinary memories, individual variations in trauma response, peri-traumatic reactions, the role of environmental factors and how to distinguish remission of symptoms due to recovery from remission due to avoidance.
Theory of shattered assumptions
Three common assumptions that are regarded most significant in influencing response to trauma are 1) the world is benevolent, other people are in general well-disposed toward us, 2) the world is meaningful, there are reliable rules and principles that enable us to predict which behaviours will produce which kind of outcome 3) the self is worthy, we ourselves are personally good, moral, and well-meaning.
A traumatic experience has the potential to shatter deeply held and probably unexamined assumptions about how we believe the world and ourselves to be.
Updating of assumptions can take place spontaneously through the re-experiencing cycle described by Horowitz. It can also be made to occur deliberately by reflecting on the trauma.
Research has found that other assumptions may be more fundamental. For people to act in the world, they must have a set of beliefs that 1) the self is sufficiently competent to act 2) the world is sufficiently predictable 3) the world provides sufficient satisfaction of needs.
Traumatic incidents are highly unpredictable and unpleasant and produce feelings of intense helplessness, thereby challenging these beliefs. In some cases, this produces intense conflict and feelings of unreality.
According to the theory of shattered assumptions, people with the most positive experiences in life, who should therefore hold the most positive assumptions, should be the ones most affected by traumatic events. But, the opposite is the case.
Conditioning theory
An initial phase of fear acquisition through classical conditioning results in neutral stimuli present in the traumatic situation acquiring fear-eliciting properties through their association with the unconditioned stimulus. A wide variety of associated stimuli would acquire the ability to arouse fear through the processes of stimulus generalisation and higher order conditioning. Extinction would fail to occur if the person attempted to distract themselves or block out the memories, rendering the exposure incomplete. Avoidance of the conditioned stimuli would be reinforced by a reduction in fear, leading to the maintenance of PTSD.
People with PTSD develop conditioned responses more readily to aversive events in general, and these are harder to extinguish.
This approach does not clearly distinguish the etiology of PTSD from that of other anxiety disorders.
Information-processing theories
Central to information-processing theories is the idea that there is something special about the way the traumatic event is represented in memory and that if it is not processes in an appropriate way, psychopathology will result. It emphasizes the need for information about the event to be integrated within the wider memory system. The difficulty in achieving this is attributed to the characteristics of the trauma memory.
Lang proposed that frightening events were represented within memory as interconnections between nodes in an associative network. A fear memory consisted of interconnections between different nodes representing three types of propositional information 1) stimulus information about the traumatic event 2) information about the person’s emotional and physiological response to the event 3) meaning information, primarily about the degree of threat. Cognition and affect were integrated within an overall response program designed to rapidly escape or avoid danger.
Lang suggested that patients with anxiety disorders have unusually coherent and stable fear memories that are easily activated by stimulus elements, that may be ambiguous but bear some resemblance to the contents of the memory. When the fear network is activated, the person experiences the same physiological reactions and tends to make meaning judgments that accord to the original memory.
What distinguishes PTSD from other anxiety disorders is that the traumatic event is of monumental significance and violates formerly held basic concepts of safety. A traumatic event leads to a kind of representation in memory that is different from one created in everyday experience. Fear networks in PTSD are characterized by 1) particularly strong response elements. 2) the overturning of basic assumptions about safety means that there will be a large number of environmental cues that cause the network to be activated. 3) The network has a low threshold of activation.
For information in the fear network to be integrated with the rest of a person’s memories, these strong associations would have to be weakened. The strength of the interconnections within the fear memory would have to be reduced so that other non-threatening memories could also be activated. In order to do this, the fear network needs to be activated, and modified by incorporating information that is incompatible with it.
PTSD reactions tend to persist when achieving exposure of sufficient length in all the elements in the fear network is difficult. Under these circumstances, only some associations are weakened.
Anxious apprehension model
Cognitive factors that occur after the trauma produce a feedback cycle of anxious apprehension. Patients with PTSD focus their attention upon and are hypervigilant for information about ‘emotional alarms’ and associated stimuli. False alarms occur subsequently in the absence of danger.
In PTSD, the focus of people’s anxious apprehension is on cognitive and physiological cues from the time of the actual trauma as they wish to avoid distress generated by alarms. The learned alarms generate hyperarousal symptoms, which through their association to cues present at the time of the trauma, result in a negative feedback loop ensuring successive re-experiencing symptoms. To prevent triggering of alarms, the person will tend to avoid emotional interoceptive information.
Emotional processing theory
The network theory has been elaborated. Individuals with more rigid pre-trauma views would be more vulnerable to PTSD. These could be rigid positive views about the self and the world, which would be contradicted, or rigid negative views which would be confirmed.
Negative appraisals of responses and behaviours could exacerbate perceptions of incompetence. These might relate to 1) events that took place at the time of the trauma 2) symptoms that developed afterwards 3) disruptions in daily activities 4) responses of others.
Beliefs that were present before, during and after the trauma could interact to reinforce the critical negative schema’s involving incompetence and danger that underlie chronic PTSD.
A number of mechanisms is thought to be involved in exposure treatment 1) repeated reliving should promote the habituation of fear. Reducing the level of fear associated with other elements in the trauma memory as well as countering the belief that such anxiety is permanent 2) it prevents avoidance of the trauma memory being negative reinforced 3) rehearsing trauma memory in a therapeutic environment incorporates safety information into the trauma memory 4) the trauma can be better discriminated from other potentially threatening events and seen as a specific case rather than one among many examples 5) exposure offers the possibility to experience the self as showing mastery and courage in the face of challenge 6) by reflecting on events in detail, patients may reject previous negative evaluations as being inconsistent with the evidence 7) the severity of the event frequently disrupts the cognitive processes of attention and memory at the time of the trauma and produces dissociative states. This leads to the formation of a disjointed and fragmented fear structure. Repeated reliving generates a more organized memory record that is easier to integrate.
Empirical evidence
The treatment method associated with emotional processing theory, prolonged exposure, is well established as a highly effective treatment for PTSD.
Improvement is related to reductions in levels of fear between treatment sessions, but not to reductions in fear within sessions.
The prediction that higher levels of fragmentation and disorganisation in the trauma narrative are related to the occurrence of dissociative responses has received relatively consistent support.
There is little evidence that dissociation leads to trauma narratives that are shorter and more simplistic.
There is no consistent evidence that improvement in therapy is related to changes in the structure of trauma memories, the initial activation of fear, or to habituation.
A general problem with the associative memory network approach is that it cannot represent knowledge at levels of meaning beyond that of the word or sentence, whereas there is reason for thinking that the meaning of emotional events tends to be complex.
Dual representation theory
Pathological responses arise when trauma memories become dissociated form the ordinary memory system and that recovery involves transforming then into ordinary or narrative memories. Unclear is if ordinary memories of the traumatic event can exist alongside dissociated memories, and how one form of memory is transformed.
One way of understanding this is to posit that there are two (or more) memory systems and that trauma information is better represented in one system than in the other. Cognitive psychologists proposed that there is a separate perceptual memory system that records information that has received little, if any, conscious attention. Experiencing events with high levels of emotion or importance results in the storage of long-lasting, vivid traces.
Brewin’s version of dual representation theory, two memory systems continue to operate in parallel. One may take precedence over the other at different times. 1) Verbally assessable memory system (VAM), reflected by oral or written narrative memories of trauma. Trauma memory is here integrated in with other autobiographical memories. These can be deliberately retrieved as and when required. These are represented within a complete personal context comprising past, present and future. The amount of information they contain is restricted because they only record what has been consciously attended to. These include emotions that happened at the time and generated by retrospective cognitive appraisal. 2) Situationally accessible memory system (SAM), triggered involuntary by situational reminders of the trauma. Contains information that has been obtained from more extensive, lower level perceptual processing of the traumatic scene that were too briefly apprehended to receive much conscious attention and did not become recorded in the VAM system. SAM also stores information about the person’s bodily response. This results in flashback being more detailed and emotion-laden than ordinary memories. This does not use a verbal code, making it difficult to communicate to others. It does not necessarily interact with and get updated by other autobiographical knowledge. They can be difficult to control. Emotions that accompany SAM memories are restricted to primary emotions that were experienced during the trauma.
PTSD is a hybrid disorder that potentially incorporates two separate pathological processes 1) involving the resolution of negative beliefs and their accompanying emotions 2) involving the management of flashbacks.
Requirements to recovery are: 1) reduce negative emotions generated by cognitive appraisal of the trauma, by consciously reasserting perceived control, reattributing responsibility, and achieving an integration of the new information with pre-existing concepts and beliefs 2) to prevent the continued automatic reactivation of situationally accessible knowledge about the trauma.
It was suggested that this is brought about by creating new SAMs that block access to the original ones. These would consist of the original trauma images paired with states of reduced arousal and reduced negative affect brought about by habituation or by cognitive restructuring of the meaning and significance of the event.
Neuropsychology and dual representation theory
Brewin highlighted the importance of the amygdala in activating fear responses and the different pathways that could convey trauma information to the amygdala. 1) Pathways involving processing by the hippocampus would result in the laying down of integrated, coherent representations of conscious experience, located in temporal and spatial context. These would be available for deliberate recall 2) Memories formed by an alternative pathway would not be open to deliberate recall, or locatable in a broader temporal or spatial context. These would be accessed automatically by reminders similar to those recorded in the trauma memory
Prolonged tress inhibits the functioning of the functioning of the hippocampus. This tends to reverse the improvement in declarative memory. Functioning of the amygdala appears enhanced as stress increases.
Verbally accessible memories suggest a form of representation that is dependent on the hippocampus. Because temporal context is encoded, they are experienced as in the past. Situationally accessible memories, experienced as happening in the present, highly perceptual,, elicited automatically, suggest non-hippocampally processing.
The lack of temporal context has two consequences 1) when the memories are retrieved, they are re-experienced in the present 2) the representation of ongoing threat leads to attentional and memory biases.
When the trauma survivor deliberately focuses and maintains attention on the context of the flashbacks rather than trying to suppress them, information that is only present in the SAM becomes reencoded into the VAM, at which point the memories are assigned a spatial and temporal context. This has to be repeated because there may be a lot of extra information about the trauma that has to be transferred. Eventually, providing the person is now safe, detailed memories in the SAM system that signalled the continuing presence of danger are matched by detailed memories in the VAM system that locate the danger in the past. If the new VAM memories are accessed, inhibitory pathways form the prefrontal cortex prevent inappropriate amygdala activation and the return of fear.
Dual representation theory maintains that the original trauma memories are not altered in any way, but remain intact and may be vividly re-experienced again in the future if the person unexpectedly comes across very detailed and specific reminders. Recovery is seen in terms of introducing retrieval competition.
People are thought to have in memory multiple self-representations or identities that compete to be retrieved. These identities provide a series of high-level frameworks that summarize experience with the world and with close relationships, and within which specific thoughts, images, or impulses are organized.Negative cognitions related to the trauma often arise because the event has made it difficult to retrieve positive self-identities or has reactivated negative self-identities created by previous adversity. Modifying these negative cognitions may involve exploring the existence of alternative identities that have been experienced by the person with PTSD and tracing links between these identities and the experience of trauma.
Cognitive therapy enhances the retrievability of positive identities by making them more distinctive and by creating new associative links that enable them to be retrieved following the activation of negative thoughts or images. Old representations remain unchanged and remain their potential to be retrieved by the right combination of cues.
Empirical evidence
The claim of dual representation that intrusive trauma images are supported by a different memory system, one that is predominantly visual is supported.
This theory is not linked to a detailed outline of therapeutic procedure.
Ehlers and Clark’s cognitive model
Pathological response to trauma arise when individual process the traumatic information in a way that produces a sense of current threat (external as well as internal).Two major mechanisms produce this effect: 1) negative appraisals of the trauma or its sequelae 2) the nature of the trauma memory.
The different types of appraisal explain the variety of emotions reported by patients with PTSD.
Among the factors that increase the likelihood of negative appraisals are: 1) thought processes during the trauma. Mental defeat is a risk factor for such self-appraisals as being weak, ineffective, or unable to protect oneself 2) prior beliefs and experiences.
Memory of the traumatic event is poorly elaborated, not given a complete context in time and place, and inadequately integrated into the general database of autobiographical knowledge. This accounts for: 1) the difficulty of intentional recall 2) re-experiencing in the present 3) the lack of connection with other information 4) easy triggering by physically similar cues.
Strong S-S and S-R associations for traumatic material are formed which help the person to make predictions about future sources of danger. Retrieval from associative memory is cue-driven and unintentional, so that the person may be unaware of the triggers for re-experiencing. Strong associations result in perceptual priming
There are a number of peri-traumatic influences that operate at encoding. They affect the nature of trauma memory 1) the distinction between data-driven processing (focused on sensory impressions) and conceptual processing (focused on the meaning of the situation, organizing the information, and placing it into context). Conceptual processing facilitates integration of the trauma memory with the autobiographical database. Data-driven processing leads to strong perceptual priming and memory that is hard to retrieve intentionally 2) an inability to establish a self-referential perspective while experiencing the trauma 3) dissociation 4) emotional numbing 5) lack of cognitive capacity to evaluate aspects of the event accurately.
Maladaptive behavioural strategies and cognitive processing styles maintain the disorder. Among the behavioural strategies likely to cause PTSD to persist are: 1) active attempts at thought suppression 2) distraction 3) avoidance of trauma reminders 4) use of alcohol or medication to control anxiety 5) abandonment of normal activities 6) adaption of safety behaviours to prevent or minimize trauma-related negative outcomes.
Empirical evidence
There is good evidence in support of various aspects of the model.
Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults.
Brewin, C.R., Andrews, B., & Valentine, J.D. (2000).
Journal of Consulting and Clinical Psychology, 68(5), 748-766.
Predictors of posttraumatic stress disorder and symptoms in adults: a meta-anlaysis
Ozer, Weiss & Lipsey 2003
Exposure to trauma may not always be sufficient to explain the development of PTSD, but when people are exposed to traumatic events, the risk of PTSD is enhanced reliably. Individual vulnerability factors have a role to play in understanding PTSD.
The strongest predictors of PTSD are factors occuring during of after the trauma.
Gender, age at trauma and race predict PTSD in some populations, but not others. Education, previous trauma and general childhood adversity predicts PTSD more consistently but to a varying extend. Psychiatric history, reported childhood abuse, and family psychiatric history have predictive effects.
By a relatively small extent, the risk of PTSD is enhanced by the effects of: female gender, greater social, educational and intellectual disadvantages, psychiatric history and various types of previous adversity
The risk of PTSD is enhanced by factors occurring during or after the trauma like: peritraumatic dissociation, preceived support, preceived life threat and peritraumatic emotions.
Reformulating PTSD for DSM-V: Life after Criterion
Brewin, C.R., Lanius, R.A., Novac, A., Schnyder, U., & Galea, S. (2009)
A. Journal of Traumatic Stress, 22, 366-373.
The diagnosis of posttraumatic stress disorder has been criticised on three main reasons, namely: 1) the alleged pathologizing of normal events 2) the inadequacy of criterion A 3) symptom overlap with other disorders.
PTSD has a multifactorial etiology.
Criticism 1: PTSD pathologizes normal distress
One criticism of PTSD is that it creates a medical condition out of normal distress.
Studies show that extreme stress sometimes leads to severe and long-lasting psychopathology, as well as to a variety of serious medical conditions.
A popular view currently is that PTSD reflects a failure of adaptation, whereby normal reactions to extreme stress do not correct themselves. What is pathological about PTSD is defined by the persistence of its symptoms.
Evidence supports a distinctive biological profile associated with PTSD.
Criticism 2: inadequacy of criterion A
Three fundamental issues with the A criterion are: 1) how broadly or narrowly should trauma be defined? 2) can trauma be measured reliably and validly? 3) what is the relationship between trauma and PTSD?
Trauma is not exclusively associated with PTSD.
Other disorders are linked to traumatic (criterion A) events
Trauma is associated with an increased prevalence of other disorders. If these can be diagnosed after a traumatic event, the question arises why the same could not be true of PTSD.
Trauma’s do not increase the risk for other disorders independently of the increased risk for PTSD. PTSD plays a central role in the psychological response to trauma.
Insufficient specificity of criterion A
The original conceptualization of PTSD was a response to an event ‘generally outside the range of usual human experience’. This was broadened, due to which there is a conceptual creep that is causing PTSD to be diagnosed in response to situations that are far removed from the original concept of trauma (according to critics).
There are few cases with PTSD after circumstances like divorce or money problems.
Trauma of lower intensity would be expected to provoke PTSD in vulnerable individuals with a limited capacity do dampen ther physiological response to stress. Such vulnerability may be genetic, interacting with lifetime exposure to trauma or epigenetic. It can also be related to greater levels of
.....read moreTesting a DSM-5 reformulation of posttraumatic stress disorder: Impact on prevalence and comorbidity among treatment-seeking civilian trauma survivors.
Van Emmerik, A.A.P., & Kamphuis, J.H. (2011).
Journal of Traumatic Stress, 24, 213-217.
The Brewin criteria for PTSD suggest abolishing criterion A, and retaining a subset of symptoms from criteria B to D, as well as the duration (criterion E) and impairment (criterion F) criteria. The symptom criteria Brewin proposes are: 1) distressing dreams 2) vivid daytie images or flashbacks 3) avoidance of internal trauma reminders 4) hypervigilance 5) exaggerated startle response.
The Brewin criteria do no appreciably affect overall PTSD prevalence or comorbidity. They do impact diagnostic status at the individual level. Approximately two-thirds of participants who lost the PTSD diagnosis qualified for treatment for a comorbid disorder. Reducing symptom overlap of PTSD with depression and anxiety disorders did not reduce comorbidity.
Criterion A is not essential to diagnosing PTSD.
Comparison of DSM-IV and proposed ICD-11 formulations of PTSD among civilian survivors of war and war veterans
Morina, N., Van Emmerik, A.A.P., Andrews, B., & Brewin, C.R. (2014).
Journal of Traumatic Stress, 27, 647-654
Proposals for the ICD-11 have included a reduction and simplification in the symptoms required for a PTSD diagnosis. An proposed innovation involves specifying core elements rather than typical features of PTSD. Core elements are those that on empirical or theoretical grounds most clearly distinguish PTSD from other disorders.
Core elements consist of: 1) re-experiencing the traumatic event(s) in the present, a evidenced by either flashbacks or nightmares, accompanied by fear or horror. Flashbacks are intrusive waking memories in which re-experiencing in the present can vary from a transient sensation to a complete disconnection from the current environment. 2) Avoidance of intrusions, evidenced by marked internal avoidance of thoughts and memories, or external avoidance of activities or situations 3) Excessive sense of current threat, evidenced by hypervigilane or exaggerated startle.
PTSD is defined in terms of the presence of at least one of the two symptoms of each of these core elements. In addition there must be impairment in functioning.
The new approach proposed for ICD-11 need not make a substantial difference to PTSD prevalence.
The 17 symptoms described in the DSM-IV are not all required to access PTSD.
More individuals meet the avoidance criterion in the ICD-11 system.
The reduced set of symptoms led to less comorbidity.
A cognitive model of posttraumatic stress disorder
Ehlers, A., & Clark, D.M. (2000)
Behaviour Research and Therapy, 38, 319-345.
PTSD becomes persistent when individuals process trauma in a way that leads to a sense of serous, current threat. This sense of threat arises as a consequence of: 1) excessively negative appraisals of the trauma and/or its sequelae 2) a disturbance of autobiographical memory. This is characterized by poor elaboration and contextualisation, strong associative memory and strong perceptual priming.
Change in the negative appraisals and trauma memory are prevented by a series of problematic behavioural and cognitive strategies.
Symptoms of posttraumatic stress disorder (PTSD) include: 1) repeated and unwanted re-experiencing of the event 2) hyperarousal 3) emotional numbing 4) avoidance of stimuli (including thoughts) which could serve as reminders for the event.
Overview
PTSD occurs only if individuals process the traumatic event and/or its sequealae in a way which produces a sense of serious current threat.
Two processes lead to a sense of current threat 1) individual differences in the appraisal of the trauma and/or its sequelae 2) individual differences in the nature of the memory for the event and its link to other autobiographical memories.
Once activated, the perception of current threat is accompanied by intrusions and other reexperiencing symptoms, symptoms of arousal, anxiety and other emotional responses.
The perceived threat motivates a series of behavioural and cognitive responses that are intended to reduce perceived threat and distress in the short-term, but have the consequence of preventing cognitive change and maintaining the disorder.
Appraisal of the trauma and/or its sequelae
Individuals with PTSD are unable to see the trauma as a time-limited event that does not have global negative implications for their future. These individuals are characterized by idiosyncratic negative appraisals of the traumatic event and/or its sequelae that have the common effect of creating a sense of serous current threat. This threat can be external or internal (for example: threat to one’s view of oneself as a capable person).
Appraisal of the traumatic event
Several types of appraisal can produce a sense of current threat: 1) individuals may overgeneralise from the event, as a consequence perceive a range of normal activities as more dangerous than they really are 2) exaggerate the probability of further catastrophic events as general, or think that they ‘attract disaster’.
Appraisals of the way one felt or behaved during the even can have long-term threatening
.....read morePsychological theories of posttraumatic stress disorder.
Brewin, C.R., & Holmes, E.A. (2003)
Clinical Psychology Review, 23, 339-376
Memory and PTSD
In PTSD, there are a number of changes in memory functioning that are comparable with depressed patients: 1) a bias toward enhanced recall of trauma-related material 2) difficulties in retrieving autobiographical memories of specific incidents.
Specific changes in memory of PTSD are: 1) a contradictory patterns of recall related to the traumatic material itself. High levels of emotions are in some studies associated with more vivid and long-lasting memories, but in others with vague memories, lacking in detail and error prone. PTSD is described as characterized by both high-frequency, distressing, intrusive memories and by amnesia for the details of the event. 2) the reliving of memories, or flashbacks to the trauma. Flashbacks are dominated by sensory detail. These images and sensations are typically disjointed and fragmentary. Reliving is reflected in a distortion in the sense of time, such that the traumatic event seems to be happening in the present rather than belonging in the past. Reliving episodes are triggered involuntarily by specific reminders that relate in some way to the circumstances of the trauma.
Flashbacks are a distinctive feature of PTSD.
Individual differences in working memory capacity appear to be related to the ability to prevent unwanted material from intruding and negatively affecting task performance.
Attention and PTSD
Research does not provide evidence that the effects of an attentional bias are unique to PTSD.
Dissociation and PTSD
Dissociation are any kind of temporary breakdown in what we think of as the relatively continuous, interrelated processes of perceiving the world around us, remembering the past, or having a single identify that links our past with our future.
Mild dissociative reactions are common under stress.
Dissociative symptoms most commonly encountered in trauma include: emotional numbing, derealisation, depersonalisation, out-of-body experiences. They are related to the severity of the trauma, fear of death, and feeling helpless.
It has been suggested that such reactions reflect a defensive response related to freezing in animals.
When these symptoms occur in the course of a traumatic experience, they are referred to as ‘peri-traumatic dissociation’.
The presence of dissociative symptoms occurring after rather than during trauma is not consistently associated with risk for later PTSD.
Cognitive-affective reactions and PTSD
A requirement of the PTSD diagnosis according to the DSM-IV, is to experience intense fear, helplessness, or horror at the time of the trauma.
There is a strong relationship between each of the
.....read moreProtocollaire behandelingen voor volwassenen met psychische klachten
Hoofdstuk 6
Protocollaire behandeling van patiënten met een posttraumatische-stressstoornis: imaginaire exposure en exposure in vivo.
Een posttraumatische-stresstoornis (PTSS) kan ontstaan na het meemaken van een trauma. De belangrijkste symptomen zijn: 1) herbelevingen 2) vermijding van prikkels die geassocieerd zijn met het trauma 3) negatieve veranderingen in cognities en stemming 4) verhoogde arousal.
Als iemand naast de PTSS-symptomen ook symptomen heeft van derealisatie en/of depersonalisatie, wordt dit een dissociatief subtype genoemd.
Voor de behandeling van PTSS dis het van belang om de herinnering aan de traumatische gebeurtenis op te halen uit het geheugen en deze te bewerken. Het heeft als doel om pathologische elementen van het geheugen te corrigeren die ten grondslag liggen aan de angstsensaties. Hiervoor moet eerste het angstnetwerk in het geheugen geactiveerd worden. Ook moet nieuwe corrigerende informatie toegevoegd worden die incompatibel is met de bestaande pathologische informatie. Exposure is hiervoor geschikt.
Exposure is bewezen effectief.
Kenmerken van het trauma zelf hebben geen relatie met de behandelresultaten. Hetzelfde geld voor comorbiditeit.
Bij comorbiditeit is vaak de PTSS de centrale bron van de stoornissen. Hierbij hoeft de PTSS behandeling niet aangepast te worden.
Behandelingen waarin alleen imaginaire exposure werd toegepast zijn minder effectief dan behandelingen waarin exposure in vivo werd toegevoegd.
Factoren tijdens de behandeling zijn van invloed op het resultaat. Sociale steun en compliance aan de behandeling voorspellen het behandelresultaat. Groepsbehandelingen zijn minder effectief.
De diagnose PTSS wordt bij voorkeur gesteld aan de hand van een gestructureerd interview.
Imaginaire exposure en exposure in vivo staan centraal. De cliënt wordt herhaaldelijk en langdurig geconfronteerd met de angst oproepende herinneringen aan het trauma, door het opnieuw in gedachten te beleven. Ook wordt de cliënt blootgesteld aan triggers die de angst oproepen.
De behandeling bestaat uit tien sessies van negentig minuten.
De PTSS-klachtenschaal wordt voor elke sessie afgenomen en gescoord, en besproken. Het sessieplanningsforumulier wordt gebruikt om de sessies te plannen en de volgorde van de traumatische situaties te bepalen. De subective-units-of-distress-schaal wordt gebruikt om aan te geven hoeveel angst er op het moment wordt ervaren.
Op het formulier ‘Angstige verwachtingen’ kan de cliënt voorafgaand aan de exposure aangeven wat de gevreesde verwachting is als de exposure wordt uitgevoerd. Na de sessie kan worden aangegeven in hoeverre deze verwachtingen zijn uitgekomen.
Op
.....read moreCognitieve therapie: theorie en praktijk
Hoofdstuk 11
Cognitieve therapie bij posttraumatische stressstoornis
De cliënt met PTSS verkeert in een langdurige toestand van prikkelbaarheid en wordt geplaagd door herbelevingen en (soms) verwachting van herhaling van de gebeurtenis, fobische angst en vermijding. Ook leiden zij vaak aan gevoelens van schuld en schaamte, agressie, en verlies van eigenwaarde en vertrouwen in de wereld.
PTSS kan het best onderscheiden worden van specifieke fobie door de aan- of afwezigheid van herbelevingssymptomen en vermijdingssymptomen.
In cognitieve modellen staat de verwerking van een traumatische gebeurtenis centraal. Hiermee wordt bedoelt dat de traumatische gebeurtenis wordt opgenomen in bestaande cognitieve schema’s en/of dat nieuwe functionele schema’s worden ontwikkeld.
Traumatische gebeurtenissen zijn doorgaans complexe en overweldigende ervaringen die in strijd zijn met bestaande opvattingen van het slachtoffer over zichzelf en/of de wereld.
Een ervaring kan op verschillende manieren worden verwerkt en op verschillende manieren worden opgeslagen in het langetermijngeheugen. Hoe dit wordt opgeslagen wordt bepaald door de informatieverwerkingsprocessen die in gang worden gezet op het moment dat een individu geconfronteerd wordt met een traumatische ervaring. De nieuwe informatie komt binnen via de zintuigen. Dit kan op twee manieren worden verwerkt: 1) Data-driven processing, vooral fysieke informatie 2) Conceptually-driven processing, in verband gebracht met bestaande kennis. Hierdoor kan een ervaring worden ingepast in bestaande schema’s of opvattingen.
Hoe meer conceptually-driven verwerking, hoe minder data-driven en vice versa. Als er betekenis is gegeven aan de ervaring en deze wordt opgehaald uit het geheugen wordt de persoon niet langer overspoeld door zintuigelijke indrukken van die ervaring.
Bij cliënten met PTSS is het verwerkingsproces vastgelopen en blijft het traumatisch geheugen actief. Dit dringt zich op in de vorm van herbelevingen en trauma. Intrusies waren fragmentisch van aard. Ook lijken ze in het hier en nu plaats te vinden.
Het verwerken wordt niet alleen de angst voor de traumatische herinneringen minder, maar worden de sensorische, gefragmenteerde herinneringen ook omgezet naar een betekenisvol coherent ‘verhaal’.
Volgens sommigen zijn herbelevingen van het trauma nodig voor verwerking. Activatie van sensorische geheugen is nodig om het te kunnen transformeren in een meer abstract geheugen.
Volens Ehlers en Clark wordt de beleving van intrusies bepaald door de interpretaties die slachtoffers geven aan de aanwezigheid van intrusies. De mate waarin intrusies negatief geïnterpreteerd worden hangt samen met ervaren spanning tijdens intrusies, vermijdingsgedrag en het voorduren van PTSS-klachten. Het controleren en wegdrukken van intrusies staat gezonde verwerking in de weg, waardoor de betekenis onveranderd blijft.
Verwerking
.....read moreWriting therapies for Post-Traumatic Stress and Post-Traumatic Stress Disorder
Van Emmerik, A., & Kamphuis, J.H. (2015)
A review of procedures and outcomes
Writing is an effective psychological treatment of post-traumatic stress disorder. The model includes three phases: 1) focusing on imaginal exposure to traumatic memories 2) cognitive restructuring and coping 3) social sharing and closure.
Therapeutic model
The basic therapeutic model of writing therapy includes three phases, whose effects cannot be completely disentangled.
Imaginal exposure to traumatic memories
The goal of the first phase is to expose clients to their traumatic memories, in order to achieve habituation and extinction of the fearful and other negative emotional responses that reactivation of these memories evoke.
Clients are asked to write a detailed account of the traumatic event, focusing on the most painful facts and emotions associated with the event. Clients are instructed to write in the first person and in the present tense. They must pay attention to their sensory experiences and bodily sensations during the event and to facts and feelings they have avoided.
The clinician’s primary task is to read the client’s essay and to determine with the client 1) what are the most painful facts and feelings 2) explore if any facts or feelings have been avoided 3) instruct the client to focus on precisely these facts and feelings in subsequent writing assignments.
Cognitive restructuring and coping
Targets the maladaptive cognitions and coping behaviours that may underlie the symptoms.
Clients write their best possible advice to an imaginal close associate that has experienced the traumatic event. The advice should concern how best to deal with the event and its consequences, making use of the client’s personal experiences.
Possible elements of the advice include: 1) aspects of the event that the other person has overlooked and that may shed a more positive light on the situation 2) alternative interpretations of the event 3) adaptive ways of coping 4) reflections on the meaning that the event may acquire.
The clinicians role is to identify and challenge any dysfunctional aspects of the advice and to instruct clients to apply the advice to themselves in a subsequent assignment.
Social sharing and closure
The goals are: 1) foster or promote social support by inviting clients to share their experiences in a dignified letter to a (true) close associate. The letter should describe the most important aspects of the traumatic event and its impact on the client’s life. The letter should explicitly state its
.....read moreIn this bundle, all summaries of year 3 at the uva are bundled
Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults.
Brewin, C.R., Andrews, B., & Valentine, J.D. (2000).
Journal of Consulting and Clinical Psychology, 68(5), 748-766.
Predictors of posttraumatic stress disorder and symptoms in adults: a meta-anlaysis
Ozer, Weiss & Lipsey 2003
Exposure to trauma may not always be sufficient to explain the development of PTSD, but when people are exposed to traumatic events, the risk of PTSD is enhanced reliably. Individual vulnerability factors have a role to play in understanding PTSD.
The strongest predictors of PTSD are factors occuring during of after the trauma.
Gender, age at trauma and race predict PTSD in some populations, but not others. Education, previous trauma and general childhood adversity predicts PTSD more consistently but to a varying extend. Psychiatric history, reported childhood abuse, and family psychiatric history have predictive effects.
By a relatively small extent, the risk of PTSD is enhanced by the effects of: female gender, greater social, educational and intellectual disadvantages, psychiatric history and various types of previous adversity
The risk of PTSD is enhanced by factors occurring during or after the trauma like: peritraumatic dissociation, preceived support, preceived life threat and peritraumatic emotions.
Reformulating PTSD for DSM-V: Life after Criterion
Brewin, C.R., Lanius, R.A., Novac, A., Schnyder, U., & Galea, S. (2009)
A. Journal of Traumatic Stress, 22, 366-373.
The diagnosis of posttraumatic stress disorder has been criticised on three main reasons, namely: 1) the alleged pathologizing of normal events 2) the inadequacy of criterion A 3) symptom overlap with other disorders.
PTSD has a multifactorial etiology.
Criticism 1: PTSD pathologizes normal distress
One criticism of PTSD is that it creates a medical condition out of normal distress.
Studies show that extreme stress sometimes leads to severe and long-lasting psychopathology, as well as to a variety of serious medical conditions.
A popular view currently is that PTSD reflects a failure of adaptation, whereby normal reactions to extreme stress do not correct themselves. What is pathological about PTSD is defined by the persistence of its symptoms.
Evidence supports a distinctive biological profile associated with PTSD.
Criticism 2: inadequacy of criterion A
Three fundamental issues with the A criterion are: 1) how broadly or narrowly should trauma be defined? 2) can trauma be measured reliably and validly? 3) what is the relationship between trauma and PTSD?
Trauma is not exclusively associated with PTSD.
Other disorders are linked to traumatic (criterion A) events
Trauma is associated with an increased prevalence of other disorders. If these can be diagnosed after a traumatic event, the question arises why the same could not be true of PTSD.
Trauma’s do not increase the risk for other disorders independently of the increased risk for PTSD. PTSD plays a central role in the psychological response to trauma.
Insufficient specificity of criterion A
The original conceptualization of PTSD was a response to an event ‘generally outside the range of usual human experience’. This was broadened, due to which there is a conceptual creep that is causing PTSD to be diagnosed in response to situations that are far removed from the original concept of trauma (according to critics).
There are few cases with PTSD after circumstances like divorce or money problems.
Trauma of lower intensity would be expected to provoke PTSD in vulnerable individuals with a limited capacity do dampen ther physiological response to stress. Such vulnerability may be genetic, interacting with lifetime exposure to trauma or epigenetic. It can also be related to greater levels of
.....read moreTesting a DSM-5 reformulation of posttraumatic stress disorder: Impact on prevalence and comorbidity among treatment-seeking civilian trauma survivors.
Van Emmerik, A.A.P., & Kamphuis, J.H. (2011).
Journal of Traumatic Stress, 24, 213-217.
The Brewin criteria for PTSD suggest abolishing criterion A, and retaining a subset of symptoms from criteria B to D, as well as the duration (criterion E) and impairment (criterion F) criteria. The symptom criteria Brewin proposes are: 1) distressing dreams 2) vivid daytie images or flashbacks 3) avoidance of internal trauma reminders 4) hypervigilance 5) exaggerated startle response.
The Brewin criteria do no appreciably affect overall PTSD prevalence or comorbidity. They do impact diagnostic status at the individual level. Approximately two-thirds of participants who lost the PTSD diagnosis qualified for treatment for a comorbid disorder. Reducing symptom overlap of PTSD with depression and anxiety disorders did not reduce comorbidity.
Criterion A is not essential to diagnosing PTSD.
Comparison of DSM-IV and proposed ICD-11 formulations of PTSD among civilian survivors of war and war veterans
Morina, N., Van Emmerik, A.A.P., Andrews, B., & Brewin, C.R. (2014).
Journal of Traumatic Stress, 27, 647-654
Proposals for the ICD-11 have included a reduction and simplification in the symptoms required for a PTSD diagnosis. An proposed innovation involves specifying core elements rather than typical features of PTSD. Core elements are those that on empirical or theoretical grounds most clearly distinguish PTSD from other disorders.
Core elements consist of: 1) re-experiencing the traumatic event(s) in the present, a evidenced by either flashbacks or nightmares, accompanied by fear or horror. Flashbacks are intrusive waking memories in which re-experiencing in the present can vary from a transient sensation to a complete disconnection from the current environment. 2) Avoidance of intrusions, evidenced by marked internal avoidance of thoughts and memories, or external avoidance of activities or situations 3) Excessive sense of current threat, evidenced by hypervigilane or exaggerated startle.
PTSD is defined in terms of the presence of at least one of the two symptoms of each of these core elements. In addition there must be impairment in functioning.
The new approach proposed for ICD-11 need not make a substantial difference to PTSD prevalence.
The 17 symptoms described in the DSM-IV are not all required to access PTSD.
More individuals meet the avoidance criterion in the ICD-11 system.
The reduced set of symptoms led to less comorbidity.
A cognitive model of posttraumatic stress disorder
Ehlers, A., & Clark, D.M. (2000)
Behaviour Research and Therapy, 38, 319-345.
PTSD becomes persistent when individuals process trauma in a way that leads to a sense of serous, current threat. This sense of threat arises as a consequence of: 1) excessively negative appraisals of the trauma and/or its sequelae 2) a disturbance of autobiographical memory. This is characterized by poor elaboration and contextualisation, strong associative memory and strong perceptual priming.
Change in the negative appraisals and trauma memory are prevented by a series of problematic behavioural and cognitive strategies.
Symptoms of posttraumatic stress disorder (PTSD) include: 1) repeated and unwanted re-experiencing of the event 2) hyperarousal 3) emotional numbing 4) avoidance of stimuli (including thoughts) which could serve as reminders for the event.
Overview
PTSD occurs only if individuals process the traumatic event and/or its sequealae in a way which produces a sense of serious current threat.
Two processes lead to a sense of current threat 1) individual differences in the appraisal of the trauma and/or its sequelae 2) individual differences in the nature of the memory for the event and its link to other autobiographical memories.
Once activated, the perception of current threat is accompanied by intrusions and other reexperiencing symptoms, symptoms of arousal, anxiety and other emotional responses.
The perceived threat motivates a series of behavioural and cognitive responses that are intended to reduce perceived threat and distress in the short-term, but have the consequence of preventing cognitive change and maintaining the disorder.
Appraisal of the trauma and/or its sequelae
Individuals with PTSD are unable to see the trauma as a time-limited event that does not have global negative implications for their future. These individuals are characterized by idiosyncratic negative appraisals of the traumatic event and/or its sequelae that have the common effect of creating a sense of serous current threat. This threat can be external or internal (for example: threat to one’s view of oneself as a capable person).
Appraisal of the traumatic event
Several types of appraisal can produce a sense of current threat: 1) individuals may overgeneralise from the event, as a consequence perceive a range of normal activities as more dangerous than they really are 2) exaggerate the probability of further catastrophic events as general, or think that they ‘attract disaster’.
Appraisals of the way one felt or behaved during the even can have long-term threatening
.....read morePsychological theories of posttraumatic stress disorder.
Brewin, C.R., & Holmes, E.A. (2003)
Clinical Psychology Review, 23, 339-376
Memory and PTSD
In PTSD, there are a number of changes in memory functioning that are comparable with depressed patients: 1) a bias toward enhanced recall of trauma-related material 2) difficulties in retrieving autobiographical memories of specific incidents.
Specific changes in memory of PTSD are: 1) a contradictory patterns of recall related to the traumatic material itself. High levels of emotions are in some studies associated with more vivid and long-lasting memories, but in others with vague memories, lacking in detail and error prone. PTSD is described as characterized by both high-frequency, distressing, intrusive memories and by amnesia for the details of the event. 2) the reliving of memories, or flashbacks to the trauma. Flashbacks are dominated by sensory detail. These images and sensations are typically disjointed and fragmentary. Reliving is reflected in a distortion in the sense of time, such that the traumatic event seems to be happening in the present rather than belonging in the past. Reliving episodes are triggered involuntarily by specific reminders that relate in some way to the circumstances of the trauma.
Flashbacks are a distinctive feature of PTSD.
Individual differences in working memory capacity appear to be related to the ability to prevent unwanted material from intruding and negatively affecting task performance.
Attention and PTSD
Research does not provide evidence that the effects of an attentional bias are unique to PTSD.
Dissociation and PTSD
Dissociation are any kind of temporary breakdown in what we think of as the relatively continuous, interrelated processes of perceiving the world around us, remembering the past, or having a single identify that links our past with our future.
Mild dissociative reactions are common under stress.
Dissociative symptoms most commonly encountered in trauma include: emotional numbing, derealisation, depersonalisation, out-of-body experiences. They are related to the severity of the trauma, fear of death, and feeling helpless.
It has been suggested that such reactions reflect a defensive response related to freezing in animals.
When these symptoms occur in the course of a traumatic experience, they are referred to as ‘peri-traumatic dissociation’.
The presence of dissociative symptoms occurring after rather than during trauma is not consistently associated with risk for later PTSD.
Cognitive-affective reactions and PTSD
A requirement of the PTSD diagnosis according to the DSM-IV, is to experience intense fear, helplessness, or horror at the time of the trauma.
There is a strong relationship between each of the
.....read moreIn this bundle, you can find information about pyschiatrical disorders and clinical psychology.
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