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Posttraumatic Stress Disorder
Treating trauma
Frida Victoria Ekstedt
Speciale/Kandidatavhandling i Psykologi
Institut för kommunikation
Det humanistiska fakulitetet
Åalborg Universitet
Studienr: 20060461
Vägledare: Einar Baldursson
Juni 2008
0
Posttraumatic Stress Disorder
Which factors protects against PTSD, and why do some people seem
to be “immune” to PTSD while others have a high sensitivity to this
disorder?
How do clinicians manage the difficulties related to the treatment of
an adolescent or a child suffering from PTSD, and what is the best
treatment according to empirical findings?
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1
Abstract
Most victims recover unharmed after a traumatic experience, however some people develop
posttraumatic stress disorder. To get an understanding of why there are such individual
differences, different risk and resilience factors are discussed in this thesis. Both early and
recent theories are discussed to be able to understand and find out what type of therapy that
works for patients with PTSD. The most recent models1 all support CBT and exposure in the
treatments of PTSD, however they have different explanations why these therapies are
helpful. It is suggested that PTSD may develop because of biological or psychological
vulnerabilities, but also experiencing high stress and characteristics of the event is important.
It is argued that CBT and exposure therapy are the preferred therapies for PTSD patients,
both because of research and theoretical models. These treatments may be used for adults,
adolescents and children suffering from PTSD.
Discussed in this text: Emotional processing theory, Brewin’s dual representation theory, Ehlers and Clark’s
cognitive theory.
1
2
Introduction……………………………………………………………………6
Problem Definition…………………………………………………………………………..7
The structure of this thesis…………………………………………………………………...7
Method………………………………………………………………………………………8
Demarcation and scientific theoretic starting point………………………………………….9
Part 1) Historical Overview…………………………………………………...10
Controversies and history of PTSD…………………………………………………………10
The PTSD diagnosis………………………….……………………………………………...11
Trauma and its impact on memory…………………………………………………………..12
Memory and PTSD…………………………………………………………………………..13
Part 2) Empirical Understanding……………………………………………..16
Risk factors before a trauma………………………………………………………………..16
Risk factors that occur during a trauma…………………………………………………….17
Risk factors after the trauma…………………………..........................................................17
What is resilience and resistance?..........................................................................................18
Resilience…………………………………………………………………………………...20
Biological factors linked to resilience……………………………………………………....20
Central discussions, comments and evaluations………………………………………………....22
Methodological limitations…………………………………………………………………23
Main point from part two…………………………………………………………………..25
Part 3) Theoretical understanding…………………………………………….27
Theories for describing PTSD………………………………………………………………………27
Early Theories………………………………………………………………………………28
Conditioning Theories………………………………………………………………………29
Comments on Conditioning Theories………………………………………………………30
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Schema Theories……………………………………………………………………………30
Theory of Shattered Assumptions………………………………………………………….33
Comments on Schema Theories……………………………………………………………34
Information-processing Theories…………………………………………………………...34
Comments on information-processing theories………………………………………….....35
Recent Theories…………………………………………………………………………….35
Emotional Processing Theory……………………………………………………………………...35
The fear structure behind PTSD……………………………………………………………36
Comments on Emotional Processing Theory………………………………………………37
Ehlers and Clark’s Cognitive Theory …………………………………………………………….38
Comments on Ehlers and Clark’s Cognitive Theory……………………………………….39
Brewin’s Dual Representation Theory ……………………………………………………………40
Comments on Dual Representation Theory ………………………………………………..41
Central discussions
Comments and evaluations on early theories……………………………………………....42
Central discussions
Comments and evaluations on recent theories……………………………………………...43
Main point from part three………………………………………………………………….44
Part 4) Practical Implications, Intervention…………………………………..46
Treating post-traumatic stress disorder in adults………………………………………………..46
Exposure therapy……………………………………………………………………………46
Treatment according to dual representation theory…………………………………………47
Cognitive-behavior therapy…………………………………………………………………48
Can treatment be dangerous?.................................................................................................49
Above all, do no harm……………………………………………………………………....50
Harm in the past, harm in the present………………………………………………………51
Central discussion
Comments and evaluations on therapy for adults…………………………………………..51
Similarities between theories and therapy…………………………………………………..53
Methodological limitations………………………………………………………………….54
Main point from part four…………………………………………………………………..55
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Part 5) PTSD in children……………………………………………………………………….56
Why trauma is so damaging for children…………………………………………………...57
Risk and protective factors for traumatic stress reactions in children……………………...58
How children react to trauma………………………………………………………………59
Central discussion
Comments and evaluations…………………………………………………………………60
Treatments for children……………………………………………………………………………..61
Parental training…………………………………………………………………………….62
Exposure based techniques………………………………………………………………....63
Cognitive techniques……………………………………………………………………….64
Group cognitive-behavior therapy………………………………………………………….65
Central discussion
Comments and evaluations on therapy for children………………………………………..65
Main point from part five…………………………………………………………………..65
Summary and challenges for the future…………………………………………………….67
Conclusion……………………………………………………………………67
References……………………………………………………………………70
Appendix……………………………………………………………………..84
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Introduction
More and more people are experiencing trauma. Epidemiological studies from the United
States shows that 37-92% (depending of the sampling) of Americans have experiences a
highly traumatic event2. However, only 8% in this population will develop PTSD (Kessler et
al, 1995). How a person reacts to severe trauma can vary widely. One reaction may be
posttraumatic stress disorder (PTSD), which can cause the victim long suffering and multiple
psychological effects. The question is: why do some people develop PTSD, while others do
not? PTSD is often chronic and because it is often comorbid3 with other disorders, such as
depression, anxiety, drug abuse and increased risk of suicide makes it difficult to treat. This is
also one of the most expensive mental health disorders both in suffering and loss of the ability
to work (Friedman, Keane, & Resick, 2007). Many PTSD patients also complain of low
quality of life and problems in functioning. The major problem with PTSD is that once the
person has developed PTSD it often becomes chronic (Kessler et al., 1995). This makes it
even more important to us as practitioners to understand this disorder to better prevent and
treat it.
The aim of this work is to look at the disorder from a scientific view, to conclude which
treatments that works for patients suffering from PTSD. There are massive amounts of
research done on trauma and PTSD. This research is very confusing as one study says one
thing while another contradicts the findings of the first, for example some studies support
CBT in the treatment of PTSD while other studies have found that other treatments work
better. I have tried to make sense of some of these studies and to discuss the most recent
findings in trauma research.
In this thesis the focus is on individual differences in risk and resilience factors in
people that develop PTSD. This has been investigated in adults, adolescents and children.
Trauma is very damaging for a child both currently and for the future. This will impact
cognitive development, IQ and school performance (Veltman & Browne, 2001). This
knowledge may be useful for intervention and especially in the case of children it is very
important to treat them as soon as possible to stop further damage.
Highly traumatic event: “the person experienced a situation which could/or did result in death, major physical
harm or threat about this” (DSM-1V, 2000, p. 160).
3
Comorbid: the presence of one or more disorders in addition to a primary disorder.
2
6
I have also discussed different theories that explain PTSD. These theories are important
because they help to get an understanding for the phenomenology of PTSD, including the
symptoms of PTSD and significant linked characteristics; like the distorted thoughts about
dangers in the world, the course of post traumatic reactions and why CBT works so well for
patients with PTSD. I have chosen these theories because they are the foundation of well
documented treatments, such as cognitive behaviour therapy and exposure therapy. Other
theories and treatments such as psychodynamic or humanistic have been excluded because
there is not as much research supporting these theories and treatments.
I am aware that some treatments that are supported by research may not be valid4,
however to link research with theoretical models will be the most scientific approach. Patients
deserve to get the best treatment that will help them in recovery. However, most treatments
have side effects. In short this is the problem that will be put into light:
Problem Definition
- Which factors protects against PTSD, and why do some people seem to be “immune”
to PTSD while others have a high sensitivity to this disorder?
- How do clinicians manage the difficulties related to the treatment of an adolescent or
a child suffering from PTSD, and what is the best treatment according to empirical
findings?
The structure of this thesis
In part one, firstly history of PTSD is discussed in order to get an historical perspective on
this disorder. Secondly, how PTSD is diagnosed according to DSM-IV and a critique of this
diagnose are discussed. Thirdly, trauma and its impact on memory are discussed, to get a
better understanding on the contradictory finding found in memory research.
4
Validity: the ability of a test to measure what it was designed to measure.
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In part two, different risk and resilience factors in relation to PTSD are discussed.
These factors are investigated
-
Before
Pretraumatic factors
(i.e. biological or psychological sensitivities)
-
During
Peritraumatic factors
(i.e. intrapsychic prcesses during the trauma)
-
After
Posttraumatic factors
(i.e. social support, negative feelings after the trauma)
the traumatic exposure. This part is mainly empirical, were different research journals
are discussed. This is discussed to get an understanding why some people are very resilient to
trauma while others develop PTSD.
Part three is, theoretical where different types of theories for the understanding of
PTSD are discussed. Different research journals are discussed that support these theories. The
theories try to explain both risk and resilience factors, but also why CBT and exposure
therapy work in the treatment of PTSD. In some cases therapy has developed before the
theory, for example in emotional processing theory. No theory can explain both the therapies5
and risk and resilience factors. The discussion will include were early theories have
similarities and differences and were recent theories have similarities and differences.
Part four is, practical where therapies for the treatment of PTSD are discussed. I have
tried to link theories with therapy. It is discussed if treatment can be dangerous, if clinicians
have done harm in the past and situations that we should be aware of as clinicians treating
PTSD today. The discussion will include what therapies that are supported by which theories.
Part five is both empirical and practical, it is discussed why trauma are so damaging
for children, risk and protective factors, how children react to trauma and what type of therapy
that should be used with children. Different research journals are discussed to strengthen the
5
Cognitive-behavioural therapy and exposure therapy.
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discussion. The difficulty lies in finding the link between theories and therapy and comparing
the theoretical models.
Method
The problem formulations that have been discussed will be put in light by research articles
and books. This thesis will therefore be a work of theory, and a discussion and analysis of
these research articles. I have used both first and second hand sources, because of limitation in
time. This means that some of the research may be coloured by the author of the book who
used this source, but to be able to assess the colouring we have to find out for/against motive.
Because there is so much research on risk and resilience factors, I have looked mainly at
meta-analysis in this part of the thesis.
In this thesis a number of studies have been discussed such as: meta-analysis (i.e.
Brewin, 2003), prospective analysis (Erikson et al., 2001) and single case studies (i.e. Saigh,
1987a). A meta-analysis is a study were several studies that studies comparable research
methods, problem formulation and data are combined (Weiten, 2004). Prospective analyses is
the same as a longitudinal study, which is a correlational study, were the same person or item
is studied over a long period of time. This is a more ideal study because the person or item is
studied over a longer period (Weiten, 2004). In this way the researchers may identify
sensitivity and protective factors in people with PTSD. Unfortunately these types of studies
are expensive, so they are not used that much. A single case study is an in depth longitudinal
examination of a single instance or event. Methodological limitations will be pointed out
throughout the essay.
Demarcation and scientific theoretic starting point
This thesis was primarily supposed to concern only adults, however after finding a strong link
between experiencing trauma as a child and later sensitivity to trauma and PTSD-symptoms,
children and adolescents were also included in this work. The practical part of this essay is
focused on evidence based therapies, in the treatment part CBT, exposure therapy and how
these therapies are supported by recent theories are discussed. Also, which type of treatment
that are supported by dual representation theory, and how these therapies work. There needs
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to be proof that the therapy we use work. Clinical research can in this way improve treatments
and find out if other treatments are useless or dangerous. Other therapies and theories such as
psychodynamic or humanistic have been excluded because there is not as much research that
supports the use of these therapies in the treatment of PTSD. The theoretical models that are
included in this work have been chosen because they support evidence based therapies.
This thesis is limited to the diagnosis of posttraumatic stress disorder (PTSD). This is
because most research in the field of trauma and traumatic stress has focused on PTSD.
However, there are different types of PTSD, such as complex PTSD6 this could not be
included because of limited space. The aim of this thesis is mainly to link research, theories
and therapy, to get an understanding of how certain theories and research about the nature of
PTSD can help the clinician in their practical work. Also, to find out which different therapies
that is supported by research. There are considerable disagreements about, whom should get
help, what help these people need, and if “psychological debriefing” or other types of therapy
is helpful. After twenty-five years of research, massive amounts of research are now available
on the basis of which one can assess these arguments and competing views. My work is to
present and analyze this information with an open mind.
Part: 1) Controversies and history of PTSD
PTSD was not recognised until 1980. Before that in the late 1800, Kraepelin used “fright
neurosis” (schreckneurose) in explaining the characteristics of trauma victims (1895,
translated by Jablensky, 1985). During the Korean Conflict and after World War II, the first
DSM-I was written, this entailed the diagnosis of “gross stress reaction”. This diagnose was
given if a person showed impairment after a trauma, such as combat. However, this diagnose
fell out of fashion and was deleted in the following DSM-II. Psychiatrist John Talbot asked
for a return of the diagnosis because he had problems in diagnosing his patients when he was
working in Vietnam during the Vietnam War (Friedman, Resick, Keane, 2007).
During the 1970s, the society all over the world was changing due to social
movements and awareness of reactions following domestic violence and combat started. The
women’s movement sparked interest on sexual and physical assault on women. Laws were
changed and new legislations were introduced so that assault within families’ had to be
6
Complex PTSD: is a clinically recognised condition that results from extended exposure to prolonged social
and/or interpersonal trauma. For example incest or rape. Their symptoms are different from normal PTSD.
10
reported and was seen as crimes. Furthermore, child abuse had to be reported to the police.
The turning point was also reflected in research, Kemp and his colleagues (Gray, Cutler, Dean
& Kempe, 1977; Schmidtt & Kempe, 1975) Burgess and Holmstrom (1973, 1974) and
Walker (1979) lead to labelling of the child abuse syndrome, the battered woman syndrome
and the rape trauma syndrome, this started much more research in this area. Researchers
found that the syndromes that these trauma victims described, was much like the syndromes
that Vietnam veterans described. This resulted in a change in DSM, all trauma reactions was
classified into one diagnose PTSD. After the diagnosis of PTSD was introduced, much
research was conducted to determine, who develops PTSD and under which circumstances. In
the middle to late 1980, therapeutic treatments were published (Friedman, Resick, Keane,
2007). It should be pointed out that this is an example of the role of social norms and ideology
in diagnosis.
The PTSD diagnosis
When the DSM-III committee first developed the new diagnose of PTSD in 1980, it was a
complex task because of the lack of research (Summerfield, 2001). In practise, the diagnosis
was largely based on unofficial studies of people who had experienced combat, surviving the
Holocaust, or other extreme traumas. The work of psychoanalyst and researcher Mardi
Horowitz was very significant, he was one of the first who would make experimental studies
of responses to stressful stimuli in a laboratory environment. In his book Stress Response
Syndromes (1976) he describes a model for “how people adjust to events that overwhelm
mental defences” (Freyd, 1996).
When DSM-III committee next time needed to update the diagnosis, much more
information was available. Theories that emphasised reexperiencing and avoidance led to the
inclusion of these symptoms (Field, 1999). Furthermore, many studies shows that traumatized
people often have high levels of physiological arousal and concentration problems. These
findings led to the inclusion of the third class of hyperarousal symptoms. Much of this
research was done on combat veterans, many were soldiers returning from Vietnam. Even if
other important research was done on for example disaster victims’, military research was
very influential in the early shaping in the diagnosis of PTSD (Brewin, 2003).
To be diagnosed with PTSD according to DSM-IV, the trauma need to be serious,
such as; “experienced, witnessed, or was confronted with an event or events that involved
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actual or threatened death or serious injury, or a threat to the physical integrity of self or
others” and the person would have to feel “intense fear, helplessness or horror” (Mc Nally,
2004, p. 3) (Criterion A). With threat to physical integrity it is meant in the way that for
example rape or threat will hurt a person mentally, even if no physical harm is done. The
problem with this concept of traumatic stressor is that it is now so broad that it includes
almost any trauma and most people have experienced a traumatic stressor. In comparison in
the 1970-1980 a traumatic stressor was seen as a major catastrophe that would fall outside a
normal day’s experience. There is also a problem that the person has to feel “intense fear,
helpless or horror” in some extremely traumatic experiences the person can not bear the
trauma and “dissociates” to be able to blunt the emotional response to trauma. People that
dissociates often develop PTSD, but with this criteria these people would not get diagnosed
(McNally, 2004).
Furthermore, the person must experience at least one of the reexperiencing symptoms
(Criterion B) a traumatic flashback, dreams or disturbing memories (Brewin, 2003). There are
some problems with criterion B, it is very difficult to assess what a disturbing memory is
clearly and that only one of the criteria needs to be met to be diagnosed. Traumatic flashbacks
are one of the main reasons why memory for trauma may be different from other memories. It
also requires that the person experience at least three symptoms in the avoidance and numbing
category (Criterion C). These may be trying to avoid thoughts of the trauma and /or places
linked to the event. This criterion also includes amnesia for some parts of the experience.
PTSD also requires in minimum two arousal symptoms (Criterion D), these may be being on
edge or having sleeping problems. Finally, to be diagnosed the person must think that their
life is impaired in their work or social life. These problems must continue for at least one
month (Criterion E and F) (Brewin, 2003).
Trauma and its impact on memory
Most people better remember things or situations that are more important to them. However,
according to science high emotions may cause the memory to be worse. Many different types
of studies have concluded that high stress and arousal makes the memory worse, and other
studies have concluded that high stress and arousal make the memory better. Different studies
support the theory that emotions improve memory (Brewin, 2003).
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Studies of flashbulb memory show that people often remember upsetting events like
the death of President John F. Kennedy and other famous people very well. The vivid
memories of this day included; what the person was doing, the location they were at and who
informed them about this sad event. These flashbulb memories are often not completely
accurate and flashbulb memories are often created if it is an event that is personally important
(Brewin, 2003).
According to David Pillemer experiences that are of personal importance often create
long lasting memories of the event. For example: romantic magnetism, or the first meeting
with a person who would later show to be of importance, it may also be a change in
someone’s life. Strangely enough it may not show until later how important this encounter
may have been (Young, 1990). Pillermer proposed that these memories were often of personal
importance and with high emotion, and that is why they were remembered so vividly and it is
the combination that makes them special.
Other psychologists (i.e: Neisser, 1982) hold the view that emotion is likely to make
the memory worse. They propose that because emotion often makes the person narrow their
attention, it is unlikely that it would lead to better memory or more detailed memory. Also
emotion is often seen as being disruptive on memory processes. Researchers who want to find
out about these questions often present the participant with two different kinds of movies. In
the first version of the film there is a violent scene and in the second version the film is
similar except there is a neutral scene. After seeing the different films participants have to try
to remember as many facts as possible form these films, they more often remember things
from the neutral film (Brewin, 2003).
During the end of 1980, most eye witness experts believed that high levels of arousal
would make memory worse (Brewin, 2003). However, new research support the view that
correctness7 of recall may be both excellent and poor, depending on what needs to be
remembered. High levels of arousal may cause a reduction of attention so that less
information is encoded. However, it may be that the information encoded is better
remembered. Another hypothesis about memory and stress is called the Yerkes-Dodson law
(Van Velsen et al., 1996). According to this law “the relation between arousal and
performance on a task often takes the form of an inverted U, so that performance tends to be
best at moderate levels of arousal and worse at very high and very low levels of arousal”
(Brewin, 2003, p. 96). Stress and arousal are linked to each other and many psychologists now
7
Correctness in this sense means to be free from errors.
13
also hold the view that stress and memory functioning may also have the shape of an inverted
U.
Memory and PTSD
In the texts about PTSD, contradictory findings about memory are also found. This is seen in
the DSM-IV diagnose of PTSD, were a person with PTSD should often experience distressing
and disturbing memories that are hard to forget. According to trauma expert Bessel von der
Kolk some traumatic memories are often unchanged even after many years. Furthermore,
traumatic memories are often very vividly described and experienced by the patient who
experience visual pictures, smells, sounds and physical sensations (Brewin, 2003).
However, also in the diagnosis of PTSD in DSM-IV is the criterion of amnesia
experienced by the patient. Most patients remember that the trauma happened, but many have
large or small memory gaps or feeling of confusion of what happened. According to trauma
experts such as Terr, Herman and van der Kolk amnesia about the trauma is as common as
remembering everything very clearly.
These contradictory findings may be explained by that there are two different types of
memory, the normal or narrative memory and the distressing memories or flash bulb
memories. Most people with PTSD have normal memories about the trauma similar to other
memories like were they went to school or about a holiday they took a while ago. After
experiencing a trauma the person often think about the trauma and tries to remember exactly
what happened, in which order and who is to blame.
The person often has to recall and tell people of the event like friends or the police.
The problem is that every time the story is retold it changes the memory of the event. This
may happen if a memory is retold and one part gets more attention than other parts. For
example if a person is in a bar fight, he may retell the story about how the other person hit
him and forgetting what he said that started the fight. This “cleaned up” version of the story
will after a while make him forget what really happened and will believe his own changed
story as the reality (Brewin, 2003).
Another symptom of PTSD is reliving the trauma, or in other words flash backs.
According to Brewin “flashbacks may be mediated by neurobiological mechanisms distinct
from those mediating intrusive thoughts” (Brewin, 2003, p. 99). According to patients with
PTSD a flash back is much more realistic and horrific than a normal memory “flashbacks are
14
much more colorful…with flashback memories I actually feel similar pain as experienced at
the time of the accident. “I actually have the same sense of apprehension and shock which I
associated with the accident” (Brewin, 2003, p. 100). This means that flashbacks are often
created during the most horrific part of the trauma, where the person may have believed they
would die or could not comprehend the horrific things witnessed. People who experience
flash backs realize that discussing certain parts of the trauma, going to the place of the trauma
or using certain words like rape may trigger a flash back.
Brewin’s theory needs more empirical research and investigation. Historians have
found evidence that contradicts Brewin’s theory about that a special mechanism causes
flashbacks. In British medical archives they have found texts describing the symptoms of
traumatized soldiers that participated in World War I and II and there was not much
mentioned about flashbacks (Jones at al., 2003). This raises the question if flashbacks are only
experienced by people after World War II, if flashbacks are caused by neurobiological
mechanisms, why did not the soldiers during these wars experience more flashbacks? It may
simply be that doctors at this time forget to ask about flashbacks or were not aware of this
symptom.
The conclusion drawn on these findings must be that traumatic memories are better
and worse remembered. During high arousal or stress the narrowing of attention makes the
person remember well the details in their view, however the details outside their attention are
not so well remembered. If the person is in very high shock this may interfere with recall,
causing the memory to be fragmented. It is a contradiction in that a traumatic memory may be
very well remembered and at the same time fragmentation may occur. It may be that there is a
difference in normal memory and flash back memories (Brewin, 2003).
15
Part: 2) Empirical Understanding
It is believed that people who have a psychological disorder may have some sort of biological
or psychological vulnerability. Between 50-75% of people experience traumas, however only
a few develop PTSD (Kessler et al, 1995). Researchers have tried to find risk and resilience
factors to be able to explain these findings. Firstly, risk factors before, during and after a
trauma will be discussed. Secondly, resilience factors will be discussed. Finally, it is
discussed if these factors are important for the development of PTSD.
Risk factors before a trauma
Researchers have found that some people have a higher vulnerability to develop PTSD. The
risks increase by being female and having a lower social economic status, this is similar to
other disorders such as depression. Other risk factors are shown in Figure 1. There are also
some risk factors that have to do with previous experiences such as; being abused in
childhood, experiencing previous trauma, having psychiatric problems or coming from a
family with psychiatric problems (Brewin, 2003). But, these factors are rather modest, the
effect size is from r = .06 to r = .18 in Brewin and colleagues meta-analysis. There are many
explanations’ for these findings but researchers are uncertain if they should be interpreted as
being a vulnerability that is biological, psychological or both. For example a child growing up
in a family with psychiatric problems, it is hard to know weather it is a genetic predisposition
that makes them ill or that this environment makes the child more vulnerable.
Lower intelligence is also a risk factor for increasing the risk to develop PTSD. These
studies were conducted on soldiers in Vietnam, measuring their intelligence before going to
war (Macklin et al., 1998). But intelligence are influenced by numerous factors such as lower
socioeconomic status or childhood neglect, this makes it hard to conclude if lower intelligence
is a factor on its own. Also, it may be that soldiers with lower IQ were more exposed to
trauma, because they were the ones mostly put in the front lines.
16
Effect size (r)
0.4
0.3
0.2
0.1
Female
gender
Low
socioeconomic
Lack of
Low IQ
education
Psychiatric Childhood
history
status
abuse
Post
Trauma
trauma
severity
Lack of social 8
support
life stress
Figure 1, Risk factors for PTSD (Brewin, 2003).
Risk factors that occur during trauma
There are many different reactions that can happen during a trauma and one little understood
is dissociation. Dissociation is when there is a temporary breakdown in being conscious about
the world around us (Spiegel & Cardena, 1991). For example; daydreaming, losing track of
time, or driving a car but thinking about something completely different. According to
Charles Myers who was treating soldiers during World War I, dissociation was very common:
“Typically the immediate result of the trauma is a certain loss of consciousness. But this may
vary from a slight, momentary, almost imperceptible dizziness or clouding to profound and
lasting unconsciousness” (Myers, 1940).
8
Lack of social support: usually means social isolation, but may be connected to other factors.
17
Dissociation is thought to be a defence reaction protecting the person during extreme
stress, for example extreme dissociation may develop separate personalities if a child
experience deep trauma and recurring threats to the child’s integrity (van Kolk et al., 1996).
The reactions soldiers report are less severe, 96% of soldiers experience dissociative
symptoms during survival training (Morgan et al., 2001). The idea that dissociation defends
the person during extreme stress is because soldiers feel less pain and fear during this state.
Furthermore, the heart rate goes down, in comparison to the normal reaction that the heart rate
will go up during stress. However, research shows that dissociation is not protective but
instead increases the likelihood of developing PTSD. They are not yet sure why this happens.
It may be because a trauma has to be very severe for a person to dissociate and thus that
dissociation increases the likelihood of developing PTSD may be because the trauma is more
severe (van Kolk et al., 1996).
Victims of torture often use dissociative reactions to shield themselves against fear
and pain, they may also go into a state of feelings of helplessness and mental defeat9.
According to Ehler (2000) who has studied the reactions on former political prisoners in East
Germany, mental defeat is very important in predicting PTSD. Ehler believed that because
torture was used to break the prisoners’ spirit, mental defeat would be the reaction. As
predicted prisoners who were later diagnosed with chronic PTSD, had believed that they
would die during the torture, and that their life never would be the same (Ehlers et al., 2000).
Another study by Basoglu and colleagues (1997) shows that political activists are less
traumatised by torture in comparison to non activists, even if they are more tortured. This may
be because activists are more prepared for torture, most of them have experienced threat
before, they are used to belong to a minority and hold alternative not often accepted beliefs
and their reaction is in the form of mental defeat (Ehlers, Clarc et al., 1998). These findings
support the theory that how a person reacts during a trauma can predict later diagnosis of
PTSD.
Risk factors after the trauma
What occurs after a trauma has revealed to have a large influence if the person develops
PTSD. There are factors that will increase the likelihood to develop PTSD, stress is one of
them. Other factors are protective, like how strong a person social network is, is linked to a
9
Mental defeat: loss of core beliefs and values, distrust, alienation from others, shame, guilt, sense of being
permanently damaged.
18
better outcome in numerous disorders, also PTSD. However, when a person has PTSD he is
most likely be moody and socially withdrawn, which may keep people away (Friedman,
Keane & Resick, 2007). This also means that measuring social support after the fact is just
addressing a symptom, not a cause.
Negative beliefs also are linked to a poor outcome for PTSD patients. Numerous
studies have found a strong link between a negative interpretation of the trauma and the future
in people that later will develop PTSD, which is often chronic and difficult to treat (Dunmore
et al., 1999). Another important factor is how people cope with their disorder. People that are
prone to repress their distressing thoughts usually fail (Wenzlaff & Wegner, 2000) it is
believed that these people will have bigger problems in recovery, but other studies have
shown contradictory results. The commonsense view is that suppressing distressing thoughts
is a good reaction. Research shows that avoidance and thought suppression are linked to a
poorer outcome for PTSD patients (Dunmore et al., 2001).
The research can be a bit confusing, with so many risk factors being of importance
previous to, during and following a traumatic situation. However, several patterns have been
found, that shows that numerous of these factors are connected and may form pathways
leading to PTSD. For example, one important aspect is earlier exposure to other extreme
stressful situations. It is now believed by some that children who experience early and
extreme stress that go beyond a child’s coping abilities and are linked to early psychiatric
problems produce changes in the biological stress system and a reduction in hippocampus
volume (De Bellis et al, 1999). This may lead to a person who will react more severe in facing
a new trauma, and who will need a longer time to recover. In addition, according to
researchers early stress and traumatic experiences may lead to problems in producing enough
cortisol in response to trauma (Holman & Silver, 1998).
What is resilience and resistance?
It is not hard to understand why the meanings of these words can be so different understood
and interpreted. The problem is that resistance and resilience originated from engineering
were they explained the differences in metal. Resistance originally meant how resistant a
metal is to strain (without bending or breaking). Where resilience meant how flexible a metal
was, if under pressure it could “flex back”. In psychology, a stress resistant person is one who
can maintain homeostasis even under large amount of stress or trauma. Whereas, a resilient
19
person is one who experience problems during a traumatic or highly stressful situation but
who will quickly “flex back” and return to normal. Thus, a person who is resistant will show
an adaptation to stress that is flat during a pre, peri and post a highly stressful situation, and in
comparison a person who is resilient will show a path that is much more V shaped (Figure 2)
(Friedman, Keane & Resick, 2007).
Level of adjustment
Good
Path 1
Path 2
Path 3
Path 4
Bad
Pre
Peri
Post
Figure 2. Path 1: Stress resistance, Path 2: Resilience, Path 3: extended recovery (major
problems but will slowly return to normal), Path 4: Severe and major problems (will not
return to normal).
Psychologists now agree about what will make a person more resistant and resilient to trauma
and extreme stress. These people are often; optimistic, have a sense of mastery, have many
friends, are social and have an above average intelligence. But the problem lies in how to use
this information. As a psychologist we can hardly tell our patient to; be optimistic, be smart,
be competent or be social. This is why there is need for much more research in this are to find
out who is at a higher risk, for what bad outcome via which pathways (Friedman, Keane &
Resick, 2007). However, some clients with depression show both resilience and resistant
factors, but they still suffer from depression. There is also a social normative view included
20
here, most people want to believe that people with these characteristics are happy and healthy
(Baldursson, 2008).
Resilience
During the last decade there has been a large amount of research done on traumatic stress and
resilience (Layne et al., 2004). The literature is full of articles writing about resilience, but the
meaning is different from; resilience, risk factor, vulnerability factor, and stress resistance
(Layne et al., 2004). Other interpretations of the word resilience is “the individual’s capacity
for adapting successfully and functioning competently despite experiencing chronic stress or
adversity, or following exposure to prolonged or severe trauma” (Cicchietti & Rogosh, 1997,
p. 797). Or “the possession and sustaining of key recourses that prevent or interrupt loss
cycles” (Hobfoll, Ennis, & Kay, 2000, p: 277). These many different interpretations of the
same word, makes it difficult for the precision needed in research.
According to Layne and colleges (2007), resilience refers to “the capacity of a given
system to implement early, effective adjustment processes to alleviate strain imposed by
exposure to stress, thus efficiently restoring homeostatic balance or adaptive functioning
within a given psychosocial domain following a temporary perturbation therein” (Layne et
al., 2007, p: 500). This is the concept of resilience that is mostly used and is the correct
interpretation. Due to the popularity of resilience much research have been done in this area
on all types of different populations from; children with divorced parents (Wolchik,
Ruehlman, Braver, & Sandler, 1989), children whose parents have been in the Holocaust
(Baron, Eisman, Scuello, Veyzer, & Lieberman, 1996), or victims of sexual abuse (Valentine
& Feinauer, 1993) etc. Still there is not so much literature which focuses on resilience when it
comes to posttraumatic stress disorder.
Biological factors linked to resilience
More and more evidence suggests that traumatic stress and resilience must go beyond
psychological, environmental and social factors, that biological factors must also play a part.
This may help explain why resilience to trauma can be so individually different. Thus, it
seems that resilience is a complex interaction between; biological, psychological, behavioural
21
and social factors. Some of the more important biological factors linked to trauma is allostatic
load and predisposing genetic factors (Layne, Warren, Watson, & Shalev, 2007).
When a person is exposed to a traumatic event the most natural response is to maintain
system stability, in another word homeostasis. Sterling and Eyer (1988) coined the term
“allostatis” which has the same meaning. Using this definition, allostatic stress response
systems are biological changes in the body that happen in perceived external difficulties
produced by a highly traumatic situation. “Allostasis” may be both adaptive and maladaptive,
depending on the situation and the degree of strain the person feels and how long it lasts. This
is best explained as; allostasis may be helpful for the person in that it may uphold stability
during a highly traumatic situation. But, it can also be harming the person if the levels of
neurotransmitters, neuropeptides and hormones associated with a high stress response, does
not return to normal (Layne, Warren, Watson & Shalev, 2007). According to Charney (2004)
who uses the term “allostatic load” in explaining the physiological and psychological load
that is experienced and adapted to, after a highly stressful situation. This means that trauma
victims will have an activated allostatic stress response pattern during stress, which is part of
the sensory nervous system’s neurohormonal stress response system.
Many studies have shown that high stress will increase the stress hormone cortisol.
This may be good in that cortisol increases arousal, attention, and memory; it may also
activate energy stores, and slow down reproductive and growth systems. However, if the
stress heightened levels of cortisol is not regulated and controlled by “elaborate negative
feedback systems involving glucocorticoid and mineral corticoid receptord, may generate
serious adverse effects on physical health” (Charney, 2004, in Friedman, Keane & Resick,
2007, p: 505). Researchers have found some brain differences in trauma victims, however
other researchers have found no differences. We can not draw any conclusions on these
findings. (See appendix).
22
Central discussions
Comments and evaluation
There is evidence supporting the theory that PTSD is a reaction with intense fear,
helplessness, or shock that is caused by a very traumatic situation where threat to life or
physical integrity is common. But, there is just as much evidence for that many risk factors
that occur before, during and after a trauma is important. This is in line with the idea that
individual characteristics and reactions also have a large impact on if a person will develop
PTSD. It may be that, both pretrauma risk factors and how intense the trauma is function
through common pathways to heighten the risk of later developing PTSD. This means that
PTSD may develop because of biological or psychological vulnerabilities, but also
experiencing high stress and characteristics of the event are important (Friedman, Keane &
Resick, 2007). It is interesting to note that risk factors are similar for people at all ages (See
Table 3). It may be that PTSD developed in a person with many risk factors and who
experience a smaller trauma will be different compared to a person who have many resilience
factors but who experienced a very traumatic trauma.
The significance of resilience-related factors for understanding victims of trauma is
further highlighted by recent literature that found that intervening variables as among the best
predictors of PTSD resilience (Brewin et al., 2000). In a study by Brewin and colleagues’
(2000) about which risk factors that increased the likelihood of developing PTSD, it was
evident that a person with no social support and who at the same time was under great stress,
had two of three of the largest risk factors. These risk factors had larger effect size then child
neglect history, intelligence or socioeconomic status. Even if there is not enough research in
the traumatic stress and resilience area, researchers are starting to pay more attention to the
intervening variables to easier explain the findings why trauma exposed individuals react so
differently, and why some people seem to be “immune” against PTSD. However, it is
important to note that most functional people will not develop PTSD, even if they have
experienced a very traumatic experience (Friedman, Keane & Resick, 2007).
23
Table: 3. Vulnerability factors linked to PTSD.
Pre
Peri
Post
Adults
being female
type of trauma
low social support
lower socioeconomic status
dissocation
negative social support
psychiatric problems
getting injured during
stress after the trauma
low IQ
trauma
avoidance and security
abused in childhood
seeking
experiencing previous trauma
genetic factors
Children/Adolescents
being female
type of trauma
separation from family
lower socioeconomic status
getting injured during
separation from friends
mother suffering from psychiatric
trauma
stress after the trauma
problems
genetic factors
Methodological limitations
One problem about risk and resilience factors, are that these are often investigated in
retrospective studies. In retrospective studies resilience and sensitivity factors are measured
after the trauma. There are few prospective studies that have measured these factors before the
trauma (Brewin et al., 2000). In a study by Macklin and colleagues (1998) IQ were measured
using a prospective study before the soldiers were going to the Vietnam War, this makes this
study more reliable. However, IQ is influenced by many different factors such as childhood
neglect or lower socioeconomic status, this makes it difficult to know if IQ is a factor on its
own.
In older research about risk factors for PTSD much of the evidence came from studies
of combat veterans, and these finding may not be generalizable to civilian populations
(Brewin, Andrews, & Valentine, 2000). This is the case in Macklin and colleagues (1998) and
24
Erickson and colleagues (2001) and also in a study about feelings of dissociation during the
trauma (van Kolk et al., 1996).
According to Kramer and colleagues (1997) “any proposed risk factor that has only
been evaluated in cross-sectional studies, and in which one therefore cannot establish
temporal precedence would most appropriately be classified as concomitants or consequences
of PTSD” (Vogt, King, & King, 2007, p. 105). As an example, there are no study that have
looked at the link between poor childhood family functioning and adult sensitivity to PTSD
over a longer period of time, Kramer and colleagues (1997) suggests that a longitudinal
design should be used to track the child into adulthood. It may be that poor family functioning
is not a risk factor, but that it is rather a consequence of PTSD. It is widely known that
psychiatric problems can influence testimonies from early experiences (Brewin et al., 2000)
this would be very important concerning this type of studies.
Another similar problem is found in studies about social support and PTSD, these
studies are often also cross-sectional rather than longitudinal. It is believed that people who
have low social support are at higher risk to developing PTSD, however it may be that low
social support is rather a consequence of PTSD, since people with PTSD often become
irritable and unsocial (Vogt, King, & King, 2007). A study by King, Taft, King, Hammond
and Stone (2006) looked at this problem and used a longitudinal design to figure out the link
between social support and PTSD in Gulf War I veterans. Their results showed that at least
for these participants social support was found to be a consequence of PTSD and not a
sensitivity factor for PTSD.
Another limitation with casual risk factors is that some of them may be proxy risk
factors and not causal risk factors. A “proxy risk factor is a factor that is correlated with
another risk factor, but not causally involved in the end result” (Kramer et al., 2001, p. 107).
Kraemer and colleagues (2001) explains this well “one can operationally confirm that B is a
proxy risk factor for variable A when 1) A and B are correlated; 2) either A precedes B or there
is no temporal precedence of either variable; and 3) A demonstrates a stronger relationship
with the outcome in the presence of B” (Kramer et al., 2001, In Handbook of PTSD, p. 107).
This means that almost any variable that correlates with a strong risk factor may look like a
risk factor itself. For example, it may look like minority racial status is a risk factor for PTSD,
because many of these people have limited access to work and wealth, were the real risk
factor is the lack of access to resources (Vogt, King, & King, 2007).
Also in looking at variables that seem to be important risk factors, it may turn out that
only a part of this variable is the risk factor (Kraemer et al., 2001). For example, low IQ are
25
linked to a higher sensitivity to PTSD, however it may be that only one part of IQ (i.e.,
working memory) is liked to PTSD, while another part of IQ (i.e., verbal capacity) is not.
Furthermore, a similar example is social support. Many different studies have shown that low
social support heightens the risk to develop PTSD, however it may be that one part of social
support (i.e., negative social support) are more relevant to PTSD than other part of social
support (Vogt, King, & King, 2007).
There are many examples of risk factors that may in fact be proxy risk factors, another
example is sexual category. Girls are more likely to develop PTSD, but there may be other
factors that put girls at higher risk (Vogt, King, & King, 2007). A better way of conducting
research in the future would be to identify these potential causal risk factors that cause such
associations. If researchers can better understand risk factors this may help us in
understanding why some people develop PTDS after a trauma and why others do not.
Main point from part two

It may be that, both pretrauma risk factors and how intense the trauma is function
through common pathways to heighten the risk of later developing PTSD.

This means that PTSD may develop because of biological or psychological
vulnerabilities, but also experiencing high stress and characteristics of the event are
important (Friedman, Keane & Resick, 2007).
26
Part: 3) Theories for understanding PTSD
To be able to understand and find out what type of therapy that work for patients with PTSD,
different theories will be discussed. PTSD is a complex disorder in both that it has external
causes and also that the reaction after a trauma varies much between people. Some people
seem to survive any trauma unharmed while others develop severe PTSD that may change
their personality for years (Dalgleish, 1999). To be able to explain these differences
researchers have tried to establish risk and resilience factors (see part 2). A wide variety of
factors seems to be of importance i.e., prior psychological problems, social support, IQ. These
factors have influenced the creation of theories that tries to explain how the factors mentioned
in part 2 interact with each other and how people react after a trauma (Dalgleish, 1999).
For a psychological theory to be satisfactory in explaining PTSD, many factors need
to be considered. Firstly, it must explain the phenomenology of PTSD, this is the symptoms of
PTSD and linked factors, such as thoughts about threats in the world (Janoff-Bulman, 1992).
Secondly, it must explain the course of posttraumatic reactions that PTSD symptoms are very
normal in the first period after a trauma but that these symptoms normally decrease and why
some people naturally recover and others do not. Thirdly, much research has shown that
CBT10 works for patients with PTSD, a theory should be able to explain these findings
(Riggs, Rothbaum, & Foa, 1995).
First, some of the older theories will be discussed, including conditioning, schema
theories and theory of shattered assumptions. Secondly, newer theories will be discussed,
including emotional processing theory, dual representation theory and Ehlers and Clark’s
cognitive theory of PTSD. Each theory will be described and relevant empirical research
summarised. The discussion will include where these recent theories have similarities and
differences and where the newer theories have similarities and differences. There is also a link
between some of these theories and CBT and exposure therapy that will be discussed in this
part.
10
Cognitive-behavioural therapy.
27
Early Theories
Conditioning Theories
Many PTSD researchers and specialists (i.e., Keane, Zimering, & Caddell, 1985) thinks that
Mowrer’s (1960) two-factor learning theory of fear and axiety, is one of the best to explain
the symptoms of PTSD (Weiten, 2004). According to Mowrer’s theory, fear starts because of
classical conditioning and avoidance because of operant conditioning. Classical conditioning
was developed by Pavlov “classical conditioning is a type of learning in which a stimulus
acquires the capacity to evoke a response that was originally evoked by another stimulus”
(Weiten, 2004, p. 218). In the famous study by Pavlov he realised that the dog will start to
salivate when he hears a tone, if the tone is paired with meat powder. During conditioning the
tone (NS) is paired with meat powder (UCS) and (UCR) salivation starts, after conditioning
the neutral stimulus alone (the tone) starts the response (salivation). Operant conditioning is
“forms of learning in which responses come to be controlled by their consequences” (Weiten,
2004, p. 220). According to Skinner reinforcement happen if a response is followed by
rewarding consequences (positive reinforcement) this makes the organism want to increase
the response, but also if the organism wants to get away from a painful stimuli (negative
reinforcement).
For example, Keane et al (1985) in a study about Vietnam War veterans showed that
soldiers who experienced a highly traumatic event may become conditioned to many different
types of things such as; smells or sounds, by classical conditioning. This is why things that
was earlier not seen as a threat, is suddenly starting a fear response and anxiety. Furthermore,
it is believed by Keane et al (1985) that anxiety is not only aroused by things that were near
during the trauma, many different situations will start a fear response due to higher order
conditioning and stimulus generalization. The symptoms of PTSD, such as nightmares and
thoughts about the trauma are believed to be a natural recovery, but because a high degree of
generalization and classical conditioning happens, the symptoms may become chronic
(Friedman, Keane, Resick, 2007).
In most literature repeated exposure to the traumatic situation or stimuli should
extinguish the angst felt close to the stimuli, but this contradicts the findings of Keane et al.
(1985). They believe that this does not happen, because to extinguish fear the person needs to
28
be in a situation for a prolonged time, and reexperiencing are too narrow i.e., it can not
contain all the feared stimuli. The war trauma is often also so traumatic that soldiers often do
not want to remember everything that happened. Furthermore, many felt that if they are real
men they should not complain and talk about their problems. This is a problem because
talking has been found to help, in a study by Resick (1986) women and men who had been
robed were compared. The women more often expressed their emotions about what had
happened, and they also felt much better after 1-3 months, while the men did not get better
and did not express their emotions.
Comments on Conditioning Theories
Mowrer’s theory for explaining PTSD is uncomplicated. It well explains why stimulus that
was previous neutral suddenly is feared after the trauma. Also, why people with PTSD avoids
situations that should not be feared. However, this theory can not explain why patients with
PTSD fear so many different things in comparison to people with phobia. Patients with PTSD
avoid and fear a wide range of stimulus and situations (Cahill & Foa, 2007). It has been
hypothesized that this may be because the terrible trauma that causes PTSD. This theory and
other conditioning theories do not mention symptoms of reexperiencing (i.e., nightmares and
flashbacks), which is also very common in patients with PTSD (Cahill & Foa, 2007).
Schema Theories
Personality and social psychology have influenced the different schema theories (Epstein,
1991; Horowitz, 1986). According to this theory, “people use schemata to organize
knowledge and provide a framework for future understanding” (Weiten, 2004, p. 226).
Schemata are a very good instrument for understanding the world and things in it, because of
schemata most normal situations are automatic and do not need to be thouguht about, for
example walking stairs a stair schemata is used. According to this view psychological trauma
is seen in the light of schemas, which are core assumptions and beliefs of the world and
incoming information. Furthermore, schema theories hold that traumatic experiences are
different from present assumptions and that after experiencing a trauma the victim will often
change their assumptions about the world (Friedman, Keane, Resick, 2007). Influenced by
29
Piaget’s (1971) cognitive development model, it is believed that such changes happen
through, assimilation11 and accommodation12.
Horowitz, 1986 (stress response theory) was influenced by psychoanalytic theories in
understanding stress, although this theory is mainly cognitive in the importance of cognitive
processes of traumatic events (Yule, 1999). According to Horowitz the most important
motivation in the cognitive system for processing traumatic facts are completion tendency:
“need to match new information with inner models based on older information, and the
revision of both until they agree” (Horowitz, 1986, p. 92).
Furthermore, Horowitz believes that after experiencing a very traumatic event most
people will react with a shocked reaction, after this a period of overload will happen. During
this period the person will have problems with thoughts, memories and images of the
traumatic situation, which can not be accepted with existing meaning structures. This may
start defence mechanisms so that the person will feel numb or in denial to keep the traumatic
thoughts on an unconscious level. The completion tendency keeps the traumatic thoughts in
the active memory, and these memories sometimes override the defence mechanisms which
the person thus experiences as dreams or flashbacks, when these memories are fused with preexisting models. The problem starts when the person starts to have completion tendency but
defence mechanisms sometimes override this, causing the person to fluctuate between
disruption and denial-numbing when the traumatic memories are included with long-term
meaning representations. Problems with these processes may cause the incompletely
processed traumatic thoughts to stay in active memory and never be completely absorbed in
internal mental structures, which will cause PTSD (Yule, 1999) (See figure 4).
11
12
Assimilation: the application of previous concepts to new concepts.
Accommodation: the changing of pervious concepts in the face of new information.
30
Successful
resolution
Traumatic
situation
Stunned
reaction
Information
overload
Period of
fluctuation,
Intrusion and
avoidance
Incomplete
Resolution
Chronic
PTSD
Figure 4, Horowitz trauma model
Horowitz model is important in that his view of completion, intrusion13, avoidance and denial
can explain the phenomenology of PTSD, and have influenced the classification of PTSD. His
theory also explains why a reaction to a traumatic event can become chronic. Furthermore,
Horovitz was one of the first to recognize how trauma may influence believes about the self,
the world and the future and to help a person recover cognitive change may need to be part of
the treatment (Friedman, Keane, Resick, 2007).
Theory of Shattered Assumptions
There are other theorists that have speculated in which schemas that people with PTSD may
have. The cognitive-experiential self theory by Epstein (1985) proposes that “the essence of a
person’s personality is the implicit theory of self and world that the person constructs”
(Friedman, Keane, Resick, 2007, p. 283). According to Epstein four core beliefs will change
after a trauma: believing that the world is kind and/or meaningful, that the self is worth
something, and that other people are to be trusted. Janoff-Bulman (1982) continued the work
of Epstein and agreed that most people will have the thoughts of that “the world is benevolent,
the world is meaningful, and self is worthy” (Friedman, Keane, & Resick, 2007, p.6).
However, after a very traumatic experience these thoughts and beliefs are shattered causing
the person to feel confused and hyperaroused. This means that after a trauma the victim will
either incorporate (assimilate) the new schemas into their old view of the world or change
13
reexperiencing
31
(accommodate) their view of the world. For example, a rape victim may believe that it was
her own fault for what happened, this protects her view of the world of still being a good
place (assimilation). On the other hand if the rape victim will change her pre-trauma
assumptions to the world being a dangerous place this is an example of accommodation
(Friedman, Keane, Resick, 2007).
McCann and Pearlman (1990) analysed publications on adjustments to trauma, they
then proposed seven fundamental psychological needs: frame of reference, safety,
dependency/trust of self and others, power, esteem, intimacy, and independence (Epstein,
1991; Janoff-Bulman). Furthermore, according to McCann and Pearlman (1990) persons
develop schemas that contain beliefs, presumptions, and expectations in all of the
psychological needs. McCann and Pearlman further believe that a trauma will cause
disturbances in all or some of the psychological needs. This is why their suggestions for
therapy focus around helping the client to change their (accommodate) schemas to hold the
new information. McCann and Pearlman (1990) also proposes that traumatic situations may
cause upsetting feelings, thoughts or images when they reinforce existing negative schemas,
like with a person who has faced many difficult traumas.
Comments on Schema Theories
Schema theories have been very important in furthering the knowledge about post trauma
reactions and the understanding that experiencing a trauma might change person’s thoughts
about the world. Also, that traumatic thoughts and images that may appear after a trauma may
come from an inconsistency between pre-trauma schemas and facts provided by the traumatic
situation, and that improvement requires resolution of these differences (Friedman, Keane,
Resick, 2007).
However, it is important to look at some of the problems with schema theories; they
can not explain the development and factors that contribute to PTSD. Schema theories are
excellent in explaining trauma not PTSD. Furthermore, traumatic situations change the
victims’ positive view of the world, the self and others, this may be for some victims who
have never experienced a highly traumatic event before. But, what will happen to a person
who will experience many traumas and thus already have a negative view of the world?
According to these theories should a person who experiences many traumas already have a
negative and “shattered” view of the world, and would then quickly recover from the trauma.
32
However, research shows that this is not the case, on the contrary a person who have
experienced many traumas needed longer time for recovery and developed more often chronic
PTSD (Kessler et al., 1995).
Janoff-Bulman (1992) realised the limitations of her theory and thus proposed that
“the holding of positive core assumptions will be a risk factor for greater initial psychological
disruption but may be associated with quicker recovery” (Friedman, Keane, Resick, 2007, p:
61). This have not yet been tested scientifically. Although this can not explain why victims of
many traumas often develop chronic PTSD, or why a person with early severe PTSD also
often will suffer from later severe PTSD (Rothbaum et al., 1992).
Also with Horowitz’s model there are some limitations. First, he does not consider the
question that is now a very important one in trauma research, why do some people get PTSD
and others not, even after the same experience. Also, many PTSD patients do not experience
any defence mechanisms like denial during the first weeks, or later swinging between denial
and reexperiences (Dalgleish, 1999).
Information-processing Theories
Cognitive theories that are primarily about the traumatic experience and not so much about
the personal or social perspective are referred to as information processing theories (Chemtob
et al., 1988; Creamer et al., 1992; Foa et al., 1989 and Litz & Keane, 1989). According to
information-processing theorists “like the computer, the human mind is a system that
processes information through the application of logical rules and strategies” (Hetherington &
Parke, 1999, p. 230). The main idea is that PTSD stems from wrong processing in memory of
a traumatic experience. This theory is very similar to schema and conditioning theories.
Similar to social theories these theories stress the need for information about the trauma to be
incorporated within the larger memory system. However, the differences are that according to
information-processing theories the difficulty in attaining this lies in more of the
characteristics of the traumatic memory rather than conflicting with pre-existing suppositions
and thoughts.
Most of the early information-processing theories were focused on understanding fear
conditioning and phobic responses. This is apparent in Lang’s (1979) work he changed the
behaviouristic theory about fear conditioning to a broader cognitive model. According to
Lang, traumatic situations “are represented within memory as interconnections between nodes
33
in an associative network” (Brewin & Holmes, 2003, p. 7). A fear memory are made up by
interconnections between different nodes symbolizing three categories of propositional
information: stimulus information concerning the traumatic experience, like things seen and
heard, information about emotional and physiological reaction to the trauma, and meaning
information, mainly about the amount of threat experienced.
According to Lang patients with anxiety problems have very consistent and strong fear
memories which are easily triggered by stimulus which are unclear but are similar to the
contents of the memory. If a fear structure14 is triggered, a physiological reaction starts and
the person often makes an interpretation of the feared object that is in line with the past
memory (Brewin & Holmes, 2003). Chemtob and colleagues (1988) came up with an
evolutionary perception on trauma to be able to explain why PTSD patients often have
problems with reexperiencing and have elevated levels of arousal while people who suffer
form specific phobias do not have these problems. They hypothesised that in people with
PTSD the fear network is always active, and this is why they act in a “survival mode” that
was useful during the traumatic situation.
Foa and colleagues (1989) came up with a new version of the fear network theory and
proposed that the difference between PTSD and other anxiety disorders are that in the case of
PTSD the traumatic experience are of massive significance and breach old beliefs of safety.
They believed that there should be a theory that goes further conditioning theory and more
explains the persons experience and feelings. According to their hypothesis a traumatic
experience creates a type of representation in memory that is unlike the ones formed by
normal daily experiences (Brewin & Holmes, 2003).
An example is a person that is attacked in an alleyway may form links between the
alley node, the fear node and nodes demonstrating behavioural and physical reactions that are
a much more intense than the links between the allay nodes and other feeling and behavioural
nodes, created when the person had walked into the alley before the attack. After the attack if
the person walked into an alley the fear network will be activated and this will make the
person feel hypervigilant15, the information in the fear nodes enter awareness, and feeling of
trying to avoid this information.
For information in the fear network to be incorporated into the person’s normal
memories, these strong links between the nodes have to be impaired. When this person who
fear alleys are in an alley the fear memory is activated, for the person to get better the strength
14
15
Fear structure: is often many different safe stimulus that are wrongly linked to danger.
Highly aroused.
34
of the links within the fear memory have to be decreased so that other normal non feared
memories can also be activated and take its place. To reduce these strong links, the fear
network has to be activated and changed to include new information that is contrary to it, this
can be done through in vivo or imaginal exposure (Brewin & Holmes, 2003).
Comments on Information-processing theories
These models have influenced and led to the creation of very important and successful
therapy interventions for PTSD. Furthermore, these models showed how information about a
trauma may be processed in the brain, during and after a trauma. They also propose a better
explanation of attention and memory processes.
However, one of the limitations with these early fear network models are that they can
not explain why a traumatic memory may create flashback and physical arousal but also
create disorganized memories (Brewin & Holmes, 2003). Also, the hypothesis that memories
can be changed by the adding of different new facts has shown to be contradictory to finding
in animal research. Research shows that it is more possible that old memories stay unchanged
and that fear responses are repressed by the formation of recent memories (Bouton &
Swartentruber, 1991).
Recent Theories
Emotional Processing Theory
The earlier network theory by Foa et al., (1989) has been improved by Foa and Riggs (1993)
and Foa and Rothbaum (1998), to better incorporate new knowledge about PTSD. One is to
involve more the link between PTSD and a person’s view of themselves and the world before
and after the trauma. A person who has a very rigid positive or negative view before the
trauma (i.e., I am very competent, the world is very safe) may be more vulnerable to PTSD,
because the person with the very positive rigid view would be so choked a bad thing could
happen and the person with the very negative view this would just confirm their beliefs (Foa
& Cahill, 2001
35
This theory was developed to better explain anxiety disorders and the method and result of
exposure therapy for these problems. This theory is based on two different beliefs. Firstly, that
anxiety disorders are caused by pathological fear structures16 in memory. This fear structure is
then triggered when stimuli in the milieu fits some of the feared stimuli represented in the
structure, which then results in expanding activation to connected elements, thereby starting
cognitive, behavioural, and physiological anxiety responses. In a healthy person, a fear
structure is activated and works as a map for dangerous situations and how to act during them,
i.e.; not walking close to an angry dog. In comparison a person with anxiety problems will
have fear structures that become pathological when; 1) associations among stimulus are not
realistic, 2) physical and avoidance reactions may happen even to non threatening stimuli, 3)
easily sparked responses interfere with adaptive behaviour, 4) and harmless stimulus and
responses are wrongly linked to threat (Foa & Cahill, 2001). According to Foa and Kozak
(1985) people will develop different anxiety disorders because they have different fear
structures.
Secondly, that to get successful treatment the patients fear structures needs to be
modified so that stimulus that was once feared no longer is. Two different things need to be
worked with in therapy to change a persons fear structures, 1) the fear structure must be
triggered, 2) new information that is different from the incorrect information fixed in the
structure must be presented and integrated into the fear structure. The best way to do this is to
expose the patient to harmless but feared stimuli, as in exposure therapy. This activates the
fear structure, but at the same time teaches the patient that this is a safe stimulus. It also
teaches the patient about anxiety; many patients believe that the anxiety will continue for
hours unless they get away from the situation or that they may lose control. These new facts
are encoded in exposure therapy and thus change the fear structure in the patient, in between
the sessions the patient will often have homework that will contain exposure to the same or
similar stimuli so that the person will adapt to it, which results in a non anxious person (Foa
& Cahill, 2007). This theory can explain the development of PTSD, why some people
naturally recover, and why exposure works so well in treatment of PTSD (Foa & Cahill, 2001;
Foa, Huppert, & Cahill, 2006; Foa & Jaycox, 1999).
Empirical research have consistently supported that the treatment linked to emotional
processing theory, prolonged exposure is a very effective therapy for PTSD patients (Foa et
al., 1991). Also, two studies have supported the theory that to get successful exposure therapy
A fear structure includes “interrelated representations of feared stimuli, fear responses, and the meanings
associated with them” (Foa & Cahill, 2007, p: 62).
16
36
initial activation of fear needs to happen (Foa, Riggs, Massie, & Yarczover, 1995); (Pitman et
al., 1996).
The fear structure behind PTSD
According to emotional processing theory a fear structure behind PTSD is often many
different safe stimulus that are wrongly linked to danger, and also representations of physical
nervousness and reactions that result in PTSD. Patients with PTSD experience so many
stimuli that elicit the fear structure, that they often perceive the whole world as threatening.
Furthermore, people with PTSD often have feelings of incompetence due to what happened
during the trauma and because of the symptoms of PTSD. Two very common negative beliefs
are “the world is dangerous” and “I am incompetent” these thoughts further make the PTSD
symptoms worse, which also strengthen these wrong cognitions (Foa & Rothbaum, 1998).
Emotional processing theory is evolving to include the character of the traumatic memory and
that previous experiences may influence the person’s perception of the trauma, which may
also influence which symptoms the victim develops (Foa & Jaycox, 1999; Foa & Riggs,
1993).
Most trauma victims and victims of pure stress disorder have problems with their
memories of what happened during the trauma, they have problems with disorganized and
fragmented memories (Kilpatrick, Resnick, Freedy, 1992). Foa and Riggs (1993) believe this
is due to many different factors that may get in the way with the processing of details encoded
during extreme stress. In a study by Foa, Molnar and Cashman (1995) they concluded that
patients with PTSD who undergone exposure therapy showed a better result in remembering
their traumatic memories. Furthermore, reduced fragmented memories results in reduced
anxiety and increased organized memory results in less depression. According to this theory
the victims view about the world and themselves influences how memories of the trauma is
encoded.
37
Comments on Emotional Processing Theory
Emotional processing theory was first created to get an understanding why exposure therapy
works and how to improve this type of therapy. However, it is important to understand that
just because a therapy works it does not mean that the theory behind it is correct. The way Foa
and Riggs (1993) developed this theory makes it possible to understand that experiences prior
to the trauma may be either a risk or a resilience factor. The strengths of this theory are that it
well explains why people will develop different kinds of anxiety disorders because of their
different fear structures and which activities and mechanisms that underlies why PE works so
well for PTSD (Cahill & Foa, 2007).
A limitation with this theory is that it mainly focuses on fear and danger in why people
develop PTSD. According to Dangleish and Power (2004) a traumatic memory may also start
other feelings such as bereavement and disgust. In emotional processing theory this may be
explained in that a person who experiences a loss would activate a structure were the stimuli
activates feeling of sadness instead of fear. This may also make the person feel that the world
is dangerous and the self as useless (Cahill & Foa, 2007).
Ehlers and Clark’s Cognitive Theory
Ehlers and Clark’s (2000) model have been largely influenced by cognitive theory. According
to this theory PTSD is viewed as a consequence of a person’s interpretation of believed threat.
Furthermore, PTSD is seen as an illness associated with a trauma that happened in a past
situation, as such the fear that the person still feels belongs to the past. Ehlers and Clark came
up with their model in an attempt to explain why patients feel anxiety for the future, when the
trauma happened in the past (Cahill & Foa, 2007).
According to this model patients with PTSD process the traumatic situation and/or its
results in a manner that creates present feelings of fear and threat. Two main factors lead to
these feelings, the person’s appraisals of the traumatic situation and/or its results, and the
character of the traumatic memory and how this is linked to other memories. Ehler and Clark
agree with emotional processing theory that important cognitive interpretations can be either
external threat (believing the world is dangerous) or as internal threats (having thoughts of
38
incompetence) (Cahill & Foa, 2007). Experiencing so many different types of emotional
interpretations may explain why people with PTSD often have problems with experiencing a
variety of emotions.
Also in line with this model it is hypothesized that some people with PTSD have
fragmented memory of what happened during the trauma, and when they try to remember
what happened they feel like they are in the traumatic situation again, this idea is in line with
emotional processing theory (see also Foa & Jaycox, 1999). Because a patient with PTSD
may have problems with fragmented memory a trauma memory is felt like it is happening
again, and problems with incorporating the traumatic memory with other memories, this may
be why a person feels like there is still a sense of threat. However, in other cases the patients
with PTSD have very precise memory.
There is much research that supports parts of this model, especially, about the link
between the following factors and chronic PTSD. Mental defeat (Ehlers et al., 2000); negative
interpretations of the trauma (Dunmore et al., 1997); negative interpretations of initial PTSD
symptoms (Clohessy & Ehlers, 1999); believing in permanents changes in self or life goals
(Dunmore et al., 1999); and seeking using safety behaviour and avoidance (Dunmore et al.,
1999). However, there is less evidence to support Ehlers and Clark’s view about cognitive
processing during trauma.
Comments on Ehlers and Clark’s Cognitive Theory
This model is mainly influenced by Beck’s Cognitive model (1985) and Emotional processing
theory (Foa & Jaycox, 1999) this is why this theory have the same strengths. The difference in
this theory is the shared relationship between the traumatic memory and how the person’s
appraisal17 of the trauma and what happened. According to Ehler and Clark “when individuals
with persistent PTSD recall the traumatic event, their recall is biased by their appraisals and
they selectively retrieve information that is consistent with these appraisals” (Ehler & Clark,
2000, pp. 326-327). Also the traumatic memory may influence the person’s appraisals. An
example is that a fragmented memory of the situation may cause the person to feel negatively
about themselves; “Something is wrong with me if I am unable to remember details of the
memory” (Cahill & Foa, 2007, p. 68).
17
Inerpretation
39
This model is important because it has improved the understanding of many different
types of negative appraisals and that coping factors may influence the development of chronic
PTSD. This part of the theory is supported by empirical research. They have also found a new
factor, mental defeat that may be an important risk factor. The problem with this model is that
it can not explain why cognitive therapy in addition to exposure therapy does not improve
treatment outcome (Foa el al., 2005) but that exposure therapy in addition to cognitive therapy
does improve treatment outcome (Foa & Cahill, 2006).
Brewin’s Dual Representation Theory
Brewin, Dangleish and Joseph (1995) have changed a previous representation theory (Brewin,
1989) to explain the findings in neuroscience about PTSD (Brewin, 2001). Like in many
cognitive models, Brewin’s model is also based on two divided systems in memory that
works in parallel, during and after the trauma. Two different parts of the memory does this the
verbally available memory (VAM) and the situationally available memory (SAM). VAM can
be explained as “contain information that the individual has attended to before, during, and
after the traumatic event, and that received sufficient conscious processing to be transferred to
a long-term memory store in a form that can later be deliberately retrieved” (Brewin &
Holmes, 2003, p. 356). This means that the VAM system contains sensory, meaning and
response facts about the traumatic experience, such as for example feelings of fear or
helplessness.
SAM memories contain “information that has been obtained from far more extensive,
lower level perceptual processing of the traumatic scene, such as the sights and sounds that
were too briefly apprehended to receive much conscious attention” (Brewin & Holmes, 2003,
p. 357). SAM memories are containing facts that are not available to the person and which
can not be changed. SAMs are only accessible when parts of the traumatic experience trigger
their activation. This means that the SAM system is the cause of anxiety or flashbacks. This
theory hypothesizes that SAM and VAM work in parallel and that they can explain the
symptoms of PTSD. For example, flashbacks is believed to be linked to the activation of the
SAM system, while the patients ability to remember and tell other about the trauma is
believed to be linked to the activation of the VAM system. See figure 5. (Cahill & Foa, 2007).
Brewin et al. (1991) believes that patients need to intentionally integrate the verbally
accessible information in VAM with their pre trauma beliefs of themselves and the world and
40
“the end point of this process is to reduce negative affect by restoring a sense of safety and
control, and by making appropriate adjustments to expectations about the self and the world”
(Dalgleish, 1999, p. 202). The second trauma processing, it is proposed, is the activation of
memories in SAM through contact to cues concerning the traumatic situation. This normally
occurs instinctively when the person starts to little by little to correct VAM. Changes in the
SAM system can then happen because of integration of new non-feared facts into the SAMs
(Brewin, 1989). Brewin and colleagues have clearly been influenced both by the work of
Janoff-Bulman and Foa’s fear network.
Perfect emotional processing of VAM and SAM information about the trauma may
not be possible for every person. For some people when there are too much difference
between the assumptions the person has prior and past the trauma, emotional processing of
traumatic memories may persist. In other people emotional processing may not happen
because the person avoids thoughts and memories stored in the VAM and SAM. In this case
the SAM information is still cued in some situations and the person may develop late onset
PTSD (Dalgleish, 1991). Some research has been conducted to support the dual representation
theory.
In a study by Hellawell and Brewin (2002) the aim was to test single versus dual
representation theories, on people with PTSD. The researchers first explained the differences
between normal memories and flashbacks, and then the participants were asked to write down
a detailed story about the traumatic situation. After finishing the story, participants were asked
to look back and identify parts of the written material were they had experienced both
flashbacks and ordinary memories. In line with predictions about the SAM system, in the
flashback sections subjects used extra words describing seeing, smelling, hearing, tasting and
bodily feelings also references to motion. Furthermore, they reported more primary emotions
such as fear or horror in comparison, normal memory sections included more words linked to
secondary emotions. When the subjects were writing parts of the story that they would later
label as flashbacks they felt more body changes such as breathing changes and flushing.
41
Encoding in
verbally
accessible
memory
(VAM)
Intrusive memories
and emotions,
selective recall
Traumatic
event
Contents of
awareness
Encoding in
situationally
accessible
memory
(SAM)
Flashbacks, dreams,
situational arousal
Figure 5, A schematic illustration of dual representation theory applied to PTSD (Brewin et
al., 1995)
Comments on Dual Representation Theory
Dual representation theory answers some findings about PTSD that are difficult to explain by
the theory of a single memory system. It tries to include ideas from both social-cognitive (i.e.,
Horowitz) and information-processing perspectives (i.e., the work of Lang, 1979, and Foa et
al., 1989). Dual representation theory very well explains the phenomenology of PTSD, such
as for example why people experience flashbacks. Furthermore, this theory also explains why
there are different outcomes to trauma, why some people develop chronic PTSD and others
are untouched by a traumatic event. Finally, why exposure therapy is helpful for PTSD
patients (Dalgleih, 1999).
This theory is not linked to a special type of therapy such as emotional processing
theory or Ehlers and Clark’s cognitive theory. However, it does have some suggestions for
therapy. One that stems from the idea that recovery involves the formation of alternative and
less horrific representations in memory. According to this idea, the new memories do not have
to be more correct or true: they only have to be more memorable. This makes the theory
capable to explain the effectiveness of imagery rescripting and other treatments that are not
concerned with accuracy but aim to block disturbing images by creating less horrific
alternatives.
42
The limitation with this model is that the focus is on memory and emotions and other
parts of PTSD such as emotional numbing are not included. The important part of this theory
is that it is linked to findings in cognitive neuroscience. However, there needs to be much
more research conducted before this theory can be supported completely by research (Brewin
& Holmes, 2003).
Central discussions
Comments and evaluations on early theories
There are three main categories of early theories. 1) Schema theories were the main focus is
on how trauma may change the person’s assumption and view about the world also according
to McCann and Pearlman (1990) trauma may case disturbances in all or some of the
psychological needs. 2) Conditioning theories were the main focus is on learned relationships
and avoidance behaviour. 3) Information-processing theories were the main focus is on the
traumatic experience and memories, how they are stored, encoded and retrieved and how
these memories may be changed by exposure therapy (Brewin & Holmes, 2003).
These theories are supported by research and have contributed to important insight
about PTSD. Conditioning theory well explains how trauma reminders have the ability to
bring out fear and how important avoidance is, however it lacks the cognitive understanding
to be able to explain PTSD symptoms, such as a persons beliefs about threat. Schema theories
well explain the different emotions and beliefs caused by experiencing trauma, however the
limitation here are that the difference between PTSD and other reaction such as after a
depression is not clear. Information-processing theory well explains how a traumatic event
may have an impact on a person’s reactions and memories, however it mainly consider
emotional fear and danger. There was not much research conducted on trauma and PTSD
during this time, this may have restricted these theories (Brewin & Holmes, 2003).
43
Central discussions
Comments and evaluations on recent theories
The three recent theories about PTSD have much in common. It is obvious that they have
been influenced by schema theories (i.e., Epstein, Horowitz and McCann & Pearlman) and
Janoff-Bulman. For example; in emotional processing theory they propose that people with
rigid pretrauma beliefs18 will be more vulnerable to develop PTSD. In Ehlers and Clark’s
model expanding the work of Foa and Rothbaum (1998) they identified many negative beliefs
in patients with PTSD, for example; negative feelings about themselves i.e., “I deserve bad
things happen to me”, thoughts about the trauma i.e., “People think I am a victim” or about
the PTSD symptoms, for example numbing i.e., “I will never have a happy feeling again”.
According to Ehlers and Clark these different schemas are important because they can explain
why patients with PTSD often have so many different emotions (Brewin & Holmes, 2003).
According to Brewin’s dual representation theory PTSD is a disorder that may include two
different pathological processes, one is negative beliefs (schemas) and the other is flashbacks.
Recovery relies on improving these processes.
Even if Brewin’s dual representation theory and Ehlers and Clark’s theory have many
similarities there are some differences. According to Ehlers and Clark’s model people process
the trauma experience wrong, and this causes feelings of fear to start. For dual representation
theory, processing the trauma can only be damaging if the information is more represented in
the SAM in relation to the VAM. Brewin’s dual representation is also dissimilar from
emotional processing and Ehlers and Clark’s model in that it does not propose that
disorganized or fragmented memory from the trauma heightens the risk to get PTSD (Brewin
& Holmes, 2003).
These theories differ in their view on how therapy should be used with patients with
PTSD. According to emotional processing theory exposure is important because it helps in
many ways for example; 1) repeated experience should help the habituation of feat, 2) it
prevents avoidance of the trauma memory being negatively reinforced19, 3) retelling the
trauma story in a safe and therapeutic environment puts safety information into the traumatic
memory, 4) the trauma will be seen as a specific situation, not that the whole world is
18
schemas
the strengthening of a response because it is followed by the removal of an aversive (unpleasant) stimuli
(Weiten, 2004).
19
44
dangerous, 5) it will give the patient better self-esteem, because the person will understand
that they can face their fears, etc (Brewin & Holmes, 2003).
In emotional processing theory, behavioural and cognitive avoidance may be some of
the causes why a person with PTSD does not recover. In comparison to Ehlers and Clarks
model avoidance is not so central. According to this model it is more important to change a
patient’s negative schemas, this is why the treatment based on this model focuses on cognitive
processes, and treatment based on emotional processing theory focuses on exposure to the
trauma. According to Brewin’s dual representation theory PTSD is a disorder that may
include two different pathological processes, one is negative beliefs and the other is
flashbacks. Recovery relies on improving these processes. None of these theories can explain
all the findings in part 2.
Main point from part three

The early theories are supported by research and have contributed to important
information about PTSD. These theories have also been a large influence for recent
models in PTSD.

The three recent models have much in common, they all support cognitive-behaviour
therapy and exposure therapy for PTSD.

These recent models all support the idea that exposure is important because it helps
the person in elaboration (explanation) and contextualisation (put the memory in a
context) of the trauma memory, however they have different explanations why this is
helpful.
45
Part 4) Treatment
Treating post-traumatic stress disorder in adults
The standard treatment for PTSD is cognitive-behaviour therapy (CBT) and exposure therapy
(PE), these methods have proven to be very effective, however these treatments do not always
work for everybody and others can not endure these treatments (Foa et al., 1991). In short
CBT can be explained as changing wrong beliefs about the trauma, behaviour or symptoms,
while exposure therapy is the repeated exposure to thoughts and situations the person finds
traumatic (Brewin, 2007). There are several different types of CBT which have been
described in the literature.
It may be that there are two types of treatments because human reasoning is believed
to be carried out by two systems (Sloman, 1996). The first system is associative and
automatic, it looks for patterns and similarities an example is likeness between items. The
second system is rule-based and theoretical, it looks for finding logical structures. It may be
that exposure treatment relies on associative reasoning because it tries to create new patterns
using the information from the trauma and the changes are automatic. In comparison, CBT
uses rules that are discussed in therapy (Brewin, 2007). Firstly exposure therapy will be
discussed, secondly which treatment that are supported by Brewin’s dual representation
theory and finally how cognitive behaviour therapy works for PTSD.
Exposure therapy
In line with emotional processing theory, PE20 works by activating the fear structure when
patients confront their fearful thoughts and memories by imagine or in vivo exposure. During
PE the patient has closed eyes and tries to remember and relive the traumatic situation. They
are then asked to retell their traumatic experience, including things they hear, smell and feel.
Many people will experience flashbacks during imagined exposure. The therapy session may
be recorded and the patient will listen to it until next session. This is because it may cause
more flashbacks and gradual getting used to the most feared or upsetting parts (Cahill & Foa,
2007).
20
Prolonged exposure.
46
Patients are often asked to do in vivo exposure, this is to expose themselves to feared
objects such as the car they crashed in, the street were they were robbed or the place were
they nearly died. This is also done because the person should experience a fear response to be
able to realise that the response will diminish, if staying in the situation. This is difficult and
demanding therapy, where the patient has to be motivated. However, the rewards usually
come soon, in diminished levels of fear and memories are less relived (Brewin, 2003).
According to Foa and Jaycox (1999) there are many different reasons why PE work.
People with PTSD often avoid thought of the traumatic memory through negative
reinforcement, thus they avoid the feared stimulus. This is to reduce their anxiety, the problem
is that this hinders the emotional processing. When patients instead confront the feared
stimulus or memories, the negative reinforcement of avoiding the feared situation will be
stopped and this will promote recovery. This also teaches the patient that anxiety will
disappear after staying in the feared environment (Cahill & Foa, 2007). Furthermore,
imagined or in vivo exposure may be helpful for the patient in that they can see the trauma as
an event that happened but that this does not mean that the whole world is dangerous. PE is
also helpful in that it teaches the person that this was a situation in the past not something that
is happening now, many traumatized patients feels that when remembering the situation it
feels like it happens again. Although repeated PE will make this feeling disappear (Cahill &
Foa, 2007).
Much research has been conducted on if exposure therapy works. For example,
Cooper and Clum (1989) realised that patients with PTSD who undertook individual or group
counselling did better if exposure therapy was added to the counselling, in comparison to
patients that only received counselling. However, six months after treatment some of the post
treatment effects disappeared. In another study by Foa et al. (1991) female assault victims
were put in different treatments groups to compare; prolonged exposure (PE), stress
inoculation training (SIT), supportive counselling (SC), and a wait list control group. After
the treatment, the participants who were in group SIT and PE had improved on all three PTSD
symptom clusters, in comparison the participants who was in the SC and wait list group only
improved on PTSD arousal symptoms. After a 3 month period, a follow up were conducted
and the participant in the PE group showed the most improvement on all types on PTSD
symptoms. In the PE group 55% had recovered from PTSD and no longer met the diagnostic
criteria for PTSD, 50% in the SIT and 45% in the SC group no longer met the diagnostic
criteria. I have not been able to find any research that do not support exposure therapy.
However, exposure therapy for PTSD is risky, because of these logical reasons: for example a
47
girl who have been raped, may feel even more upset if exposure to the traumatic experience is
conducted to early. This therapy works very well for phobia and anxiety, but using exposure
in the case of PTSD have to be conducted in a careful and logic manner to limit damage.
Treatment according to dual representation theory
According to Brewin’s dual representation theory PTSD is a disorder that may include two
different pathological processes, one is negative beliefs21 and the other is flashbacks.
Recovery relies on improving these processes. Negative beliefs are changed by helping the
patient in realising that they have control, they are not responsible and to integrate these new
thoughts with pre-existing beliefs and thoughts. It is also important to limit automatic
activation of situationally accessible knowledge about the trauma (flashbacks). This is done
by “creating new SAMs that will block access to the original ones” (Brewin & Holmes, 2003,
p. 12). “The new SAMs would consist of the original trauma images paired with states of
reduced arousal and reduce negative affect brought about by habituation or by cognitive
restructuring of the meaning and significance of the event” (Brewin & Holmes, 2003, p. 12).
Thus, this model supports both exposure therapy and cognitive behavioural therapy.
According to dual representation theory, exposure therapy work because it assists the
patient in creating complete, consciously accessible memories in the VAM system that are
then able to slow down amygdala activation. Brewin proposes that what suppresses flashbacks
is “the reencoding into the VAM system of critical retrieval cues that were previously
encoded only into the SAM system” (Brewin, 2007, p. 195). The aim is to reencode these
cues in a way so that they will be easily recalled, and to understand that these cues belong to
the threat in the past. It is important to use real life exposure because the patient may reencode
new cues that may not be remembered during imagined exposure.
Also, it is important to gradually expose the patient to traumatic information,
especially if the trauma has happened when the person was a child. However, if arousal
during exposure is too low it may be because traumatic pictures kept in the SAM system have
not been retrieved. On the other hand if arousal becomes too high during exposure it may
cause the person to be overabsorbed into the traumatic memory and lose contact with the
surrounding environment. This will cause frontal and hippocampal activity to be slowed down
and the traumatic memory will be experienced without moving facts from the SAM to the
21
Schemas
48
VAM. Furthermore, with patients who have had PTSD for a long time it may be useful to use
repeated episodes of exposure. The clinician may ask the person to start to recall the less
traumatic event and go on to more traumatic experiences in steps. (Brewin & Holmes, 2003).
Cognitive-behaviour therapy
When using CBT the clinician first has to get information about how the patient interprets the
traumatic event, how he reacted afterwards and how the person reason about the event. Some
people will form wrong assumptions like; It was my fault I was robbed, I should not have
walked in such a dangerous street. Other people may have formed negative beliefs about
themselves. Basically cognitive therapy proposes that emotions can be changed by changing
beliefs. This is work conducted between the clinician and the patient, working together to find
mental patterns and assumptions. The aim is to get the client to change their wrong beliefs,
and for them to understand what is wrong with their irrational thoughts (Brewin, 2003).
There is a type of cognitive therapy (cognitive processing therapy) that has been
created by Resick and Schnicke (1993) which is especially for sexually molested victims. The
patients are first educated about their problems and are then asked to write down what it
means to them and how it has affected their life. This helps the clinician to find out if the
patients have negative beliefs and to explain to the patients the link between occurrences,
thoughts and feelings. After this the patients are then requested to write down their traumatic
story and to read it every day. The patients are then educated in how to question their negative
believes. There are detailed manuals that the clinician should use.
According to Brewin (2003) the patient can learn more positive beliefs by looking at
conflicts between their behaviour and their goals. For example, a person who has experienced
a car crash may have irrational safety behaviour such as looking too much into the rear mirror
or drive very slow. This may actually cause more accidents. It is very normal for traumatized
people to develop safety behaviours, and they prolong recovery because they make the person
feel that they are in danger and that defensive mechanisms should be used (Ehlers & Clark,
2000).
It is common in patients who have PTSD to experience negative internal “voices”,
these voices tell the person that they are incompetent, cowards etc. This is not like the voices
experienced by psychotic patients. Many people with PTSD experience that they have two
49
parts of themselves that are in conflict. It is important to get the patient to understand that
these voices should not be listened to and to distance themselves from them.
Cognitive therapy have bee critiqued for not being realistic enough, that some
thoughts are not negative but actually realistic. For example; the patient who is scared of
flying, it may happen an accident or the person who caused a car accident who may not want
to drive again, because of the risk to cause another one. It is accurate that not all negative
beliefs are unrealistic, however the aim is to change only the very extreme negative beliefs
that may impair a persons life (Brewin, 2003).
It is hypothesized that cognitive-behaviour therapy is useful for patients with PTSD
because it changes negative schemas that may have been caused by the trauma. In a study by
Foa and Jaycox (in press) girls who had been assaulted and who was diagnosed with PTSD,
finished WAS and the PBRS before and after CBT. They were questioned about how
positively they see the world and themselves, results show that they viewed the world and
themselves more positively before the trauma. After CBT the participants again had more
positive schemas about the world and themselves. This study may be impaired by self report
bias, but these results still suggests that negative schemas about the word and oneself are
common in patients with PTSD, and that changing these schemas is liked to recovery
(Zoellner, Fitzgibbons, & Foa, 2004).
There is much research that supports cognitive therapy, in a book called Effective
treatments for PTSD: practice guidelines from the international society for traumatic stress
studies (Foa, Keane, & Friedman, 2000) different studies were looked at comparing CBT,
psychodynamic therapy, stress treatments, hypnotherapy, interpersonal therapy etc. In most
cases CBT showed better results in comparison to other treatments, especially exposure
therapy showed to be very useful. Longer studies show that once PTSD is treated it will
normally not return. The problem is that as many as 50% of people who get science based
therapy do not recover and some symptoms of PTSD are not very responsive to treatment
(Bradley et al., 2005).
Can treatment be dangerous?
Shortly after experiencing a trauma many counsellors use a procedure called psychological
debriefing. This is an intervention that is normally used in the first days or weeks following a
trauma, and the aim is to prevent later psychological problems like PTSD. The person is asked
50
to talk about the trauma with a counsellor and discuss feelings, thoughts and reactions it has
caused. The belief is that the person will feel better after discussing the traumatic event
(McNally, Bryant, & Ehlers, 2003).
Psychological debriefing is popular and used within; the Swedish national police, U.S.
Air Force and U.S. Secret Service. Psychological debriefing is also used within the private
sectors such as banks. It is now very frequent used by therapists working for the police or
hospitals. The main problem with this intervention is that most studies fail to prove that it
works. Still most people like debriefing and appreciate it. Some studies have even shown that
people who received debriefing did worse than people who did not receive debriefing (Mayou
et al., 2000). This has started a debate about this intervention and most mental health
professionals agree that CISD or psychological debriefing should not be used, except if there
is a longer treatment plan with other types of treatments included (McNally, Bryant, & Ehlers,
2003).
Above all, do no harm
During the past 30 years, there has been a change in the treatment and recognizing trauma
from ignoring the disorder to now treating it almost too aggressively and sometimes too soon.
Thirty years ago some clinicians asked their colleagues “Please come out of your ivory towers
into the disaster community where trauma is going unrecognized and untreated” this has now
changed to “Slow down, consider the person, the trauma and its context and above all do no
harm” (Wilson, Friedman, & Lindy, 2004, p. 432). The vast research about trauma has lead to
many improvements in treatments and the understanding of PTSD, however as clinicians we
have to be careful with this new information.
It happens that emergency workers, who have been told that talking helps, ask the
recently traumatized person to “Tell me what happened and how you feel”. The traumatized
person may be in denial or using other defence mechanisms. When a patient later gets
therapy, the clinician may feel forced into time-limited therapy because of a third part paying
(i.e., insurance company). This may cause the clinician to too early convince the patient to
talk about the trauma. Both these factors, time pressure and to “uncover” trauma memories to
soon, may cause harm to the patient (Wilson, Friedman, & Lindy, 2004).
It is a risk when these new therapies are used that the clinician oversees ego defences,
they can be useful for the person until they have the strength to work and talk about the
trauma in therapy. It could be important to acknowledge these mechanisms and their
51
importance. As clinicians is important to remember “Above all do no harm” (Wilson,
Friedman, & Lindy, 2004).
Harm in the past, harm in the present
It may be that analytic psychologists caused harm, 30 years ago when they blamed the current
trauma adults experienced to situations that happened to the patient in their childhood, instead
they should have understood the pain the present trauma had caused (Simon, 1992).
Unintentional they told the patient “Neither I nor my theory can bear the intensity of your
current pain” (Wilson, Friedman, & Lindy, 2004, p. 443). Also they may have caused harm in
patients’ who had experienced sexual abuse as a child, because they were thought to be
fantasies and not reality.
In the present there are other kinds of harm that may be caused. The problem now lies
in that the clinician may look at the trauma as too real and forget that defences and fantasies
may be protecting the patient. In the end, the therapist should also remember not to focus only
on the trauma, but also remember how traumas and other situations may have influenced the
current problem (Wilson, Friedman, & Lindy, 2004).
Central discussions
Comments and evaluations
The empirical findings support the hypothesis that Cognitive-behaviour therapy is useful for
treatment of PTSD. Also, longer follow-up studies show that once people recover from PTSD
most do not relapse. Even if case studies have shown that other therapies like psychodynamic
or humanistic/experiential therapies may be useful for PTSD, there is not very much research
existing so it is difficult to draw a strong conclusion (Bradley, 2005). The treatments that
seem to be most successful are the ones that focus on repeated exposure to the trauma
narrative in combination with in vivo exposure to feared situations or places, and on those that
focus on cognitive changes of the trauma or a combination of these treatments (Ehlers et al.,
2004). Resick, Nishith, Weaver, Astin and Feuer (2002) did a large randomized controlled
trial and compared two types of CBT, cognitive processing therapy to prolonged exposure,
52
and to a waitlist control group. The patients in the two groups who were treated with CBT
improved and the symptoms of PTSD were largely reduced.
However there are some problems with CBT and exposure, there are a lot of patients
who never finish treatments. This may be because they do not find it helpful or that they find
the exposure part to the trauma memory to difficult. In a meta-analysis by van Etten and
Taylor (1998) 15% of participants finished the treatment before time and recent studies have
shown that up to 25% chose to drop out from treatment (Resick et al., 2002). Also, some
patients do not recover from PTSD and still have the diagnosis after treatment. This may be
because they had a more severe PTSD or a PTSD that have been present for many years.
Between 35-47% of people with PTSD do not recover after treatment with cognitive or/and
exposure techniques (Foa et al., 1999). Most patients after treatment will still have some
PTSD symptoms. There is a lack of follow up studies at extended intervals. There are only
two studies that follow up the patients after 12 months. In the studies that follow up between
6-12 months after the treatment, none of these studies looked at how many patients who had
sustained improvement22 (Bradley et al., 2005).
The treatment suggested by emotional processing theory23 has shown to be very
efficient, but the main focus is to diminish fear. It may be that other feelings that PTSD
patients may have, will not decrease by exposure therapy. A new type of treatment has been
proposed that is influenced by dual representation theory this treatment includes more feelings
than fear and use different ideas of memory functioning, like retrieval competition and
distinctiveness (Brewin, 2003). However, this has not yet been supported by research, and is
mostly a suggestion were treatment may lead into the future. Ehlers and Clark’s model is the
theory that has the most complete explanations for cognitive-behavioural treatment. As how it
is with current cognitive treatment for PTSD, results show that therapy based on this model is
very effective for the treatment of PTSD (Brewin & Holmes, 2003).
Unfortunately, even if the research has done so much progress lately, only a few
practitioners implement these treatments. In a new study about which treatments clinicians
used showed that only 10% used Cognitive-behaviour therapy or exposure therapy in their
treatment of PTSD patients (Becker, Zayfert, & Anderson, 2004). What is worse in the VA,
which is the world’s major PTSD suppliers of PTSD services, less than 10% of practitioners
who are specialized in PTSD would use manualized psychotherapies in their treatments of
PTSD patients (Rosen et al., 2004).
22
23
Improved more over time
Exposure therapy
53
Implications for research for the future: to find out why some patients never finish
treatment, do they not find it useful? Can they not handle the treatment? Or do they have a
special personality trait? Also up to 50% of patients do not recover from PTSD, why is this?
Do these people have a very severe type of PTSD? Or are they suffering from a more chronic
PTSD? What can be done for people who still have some PTSD symptoms (i.e; emotional
numbing) after treatment? Finally, there needs to be more follow up studies after 12 months
or longer, to figure out how patients feel after one and a half year after treatment or longer.
Similarities between theories and therapy
In psychology there is sometimes a problem to link therapy with theories. Different types of
therapies have developed before the theories, and that is part of why the recent theories have
been created, to be able to explain why different types of therapy work. For example:
emotional processing theory was created to be able to explain why exposure therapy works
for anxiety disorders.
To explain it very simply, CBT is a type of therapy were the main goal is to help the
patient to change their wrong/negative schemas and to help them to understand what is wrong
with their irrational thoughts. According to many different theorists negative schemas like the
“world is dangerous” or “I am incompetent” is common in these patients’ and for recovery to
take place schemas needs to be changed (i.e., Epstein, 1991; Horowitz, 1986; Janoff-Bulman,
1992). In some types of CBT it is also looked at conflicts between a person’s behaviour and
goal. For example, a person who has been in a car crash will start to drive very slowly, and
this may cause an accident instead of preventing it. This is in line with Ehlers and Clark’s
theory that have developed a detailed explanation of that different maladaptive behaviour
strategies and cognitive processing styles prolong the disorder. Some of the behaviour
strategies that may prolong PTSD are: thought suppression, distraction, avoiding
things/places/people that remind of the trauma, using drugs to lessen anxiety or using safety
behaviours (Brewin & Holmes, 1993).
According to Ehlers and Clark’s theory exposure therapy work because one of the
maladaptive behaviour strategies, avoidance of trauma reminders will be likely to decrease if
the person has to experience trauma reminders instead of avoiding them. Ehlers and Clark’s
theory can best explain why CBT work for patients with PTSD. They have improved our
54
understanding of relevant negative beliefs, and have found both beliefs and maladaptive
coping factors that prolong the disorder (Brewin & Holmes, 2003).
Emotional processing theory also proposes that people with more rigid pretrauma
views would be more likely to develop PTSD. Furthermore, they propose that negative
schemas may increase the person’s belief of incompetence. This suggests that even if
emotional processing theory was developed to understand why exposure therapy works it can
also explain why CBT work for patients with PTSD. Emotional processing theory was
developed to explain anxiey disorders, PTSD is also an anxiety disorder. However, PTSD is
different to for example: phobias. Emotional processing has also been critiqued for being too
much about limiting fear.
According to Brewin’s dual representation theory PTSD is a disorder that may include
two different pathological processes, one is negative schemas and the other is flashbacks. This
model supports both exposure and cognitive behavioural therapy24.
Methodological limitation
Research based therapies for PTSD has gone from finding treatments that are supported by
research, to comparing these treatments to be able to find which works best. Many of the
studies discussed in the treatment part are comparison studies. Unfortunately most of these
studies use sample sizes that are too small to be able to investigate small differences. These
studies have therefore produced few differences between treatments. There is a need for
studies using larger sample size (Friedman, Keane, Resick, 2007).
24
For further explanation see: treatment according to dual representation theory.
55
Main point from part four

Cognitive behaviour therapy and exposure therapy are supported by research for
adults, adolescents and children.

However, almost 50% of patients do not recover from these treatments.

Unfortunately, even if the research has done so much progress lately, only a few
practitioners implement these treatments.
56
Part 5) PTSD in children
The prevalence of PTSD in children exposed to trauma is very high, ranging from 20-30%.
Furthermore, in an American study out of 500 students 30% had seen a stabbing and 26% had
witnessed a stabbing (Bell & Jenkins, 1993). Studies on children who have experienced war
and/or are refuges shows that 25-70% of theses children will develop PTSD, depending on the
exposure. Children who experience family violence show 0-90% likelihood to develop PTSD.
This disorder is also likely to affect a child in later psychological development and thus it is
very important to find and treat these children (Ehntholt & Yule, 2006).
The diagnosis of PTSD was introduced in 1980, and it was first believed that children
could not develop PTSD. However, Leonore Terr’s (1979, 1983) research on children who
have been kidnapped and hold hostage proved this assumption wrong. The belief now is that
both children and adolescent may develop PTSD if they are traumatized. It is certain that
children are even more sensitive to stress than adults and thus have the highest risk to develop
PTSD (Norris et al., 2002). However, PTSD-symptoms in children may vary at different ages
and often other reactions are seen (Terr, 1991; Yule & Williams, 1990). The diagnosis of
PTSD in children and adolescents are almost identical to the one in adults.
1) “after exposure to actual or threatened death or serious injury instead of evidencing fear,
helplessness or horror they may respond with disorganised or agitated behaviour; 2)
symptoms of re-experiencing, repetition and reenactments where children may manifest
repetitive behaviours, play re-enactments of the traumatic situation or frightening dreams
without specific content; 3) avoidance of stimuli associated with the trauma, because it is
difficult for children to report diminished interest in significant activities and constriction of
affect, these symptoms should be carefully evaluated, with reports being sought from parents,
teachers and observers; 4) hyperarousal, where it is noted that children may also exhibit
physical symptoms such as stomach aches and headaches” (Dyregrov & Yule, 2006, p: 176,
following APA, 1994).
57
Why trauma is so damaging for children
Experiencing a traumatic situation can have a very damaging effect on the development of
children, also very small children (Graham-Bermann & Seng, 2005; Lieberman & Van Horn,
2004). Research on children that are 6 years old shows that after experiencing a trauma their
IQ scores and reading abilities were lower than before the trauma (Delaney-Black et al.,
2002). Many other studies have reached the same conclusion, were abused children shoved
delayed language and cognitive development, lower IQ and worse school performance
(Veltman & Browne, 2001).
Other researchers have looked at how trauma effects the normal development of very
small children (Lieberman, 2005). The conclusion is that this is likely to be very damaging for
the child and will affect the child’s feelings of personal safety, predictability and protection
(Groves, Zuckerman, Marans, & Cohen, 1993). Children who grow up under fear and/or with
threat to their parents’ often have problems to reach the normal developmental growth, this is
seen in their emotional, social and cognitive growth, and they may even have bad physical
health (Osofsky, 1999). This is seen in a study by Graham-Bergmann and Seng (2005) were
160 children who were part of Project Head Start, the children who had experienced
maltreatment and trauma were more likely to be sick and have an overall poorer physical
health and often show PTSD symptoms. In comparison to children who had not been mal
treated or experienced a trauma. Furthermore, longitudinal studies show that mal treated or
traumatic childhood experiences will harm mental and physical health all the way into later
life (Edwards et al., 2003; Feletti et al., 1998). On the other hand children’s brain has more
plasticity in comparison to adults or adolescents. So they should have a much better ability to
overcome trauma.
Research shows that children who experience trauma have a much higher risk to
develop psychiatric disorders or physical disorders later in life (Edwards et al., 2003; Feletti et
al., 1998). The newest studies suggests that experiencing a trauma will increase the likelihood
to develop many different disorders, such as; PTSD, drug or alcohol abuse, depression, or
anxiety problems (Goenjian et al., 1995; Kilpatrick et al., 2003). One very severe problem that
children who are witnessing interpersonal violence or other trauma are decreased capacity for
emotional regulation (Allen & Tarnowski, 1989; Cheasty, Claire, & Collins, 2002). Research
in the developmental area shows that early child abuse or maltreatment disturbs the
58
development of normal emotional regulation and interpersonal skills25 (Cloitre, Miranda,
Stovall-McClough, & Collins, 2005; Manly, Cicchetti, & Barnett, 1994).
Risk and protective factors for traumatic stress reactions in children
There are many different risk factors for PTSD reactions in children, they may be genetic or
environmental, and these factors interrelate with protective factors in a very complicated way
(Harris et al., 2006). In a much traumatized environment, like during a war, risk factors often
co-occur and they are very predictive in combination but not so much alone (Sameroff, 1998).
If a child’s mother suffers from depression, anxiety or traumatic stress, the child will more
often have PTSD symptoms (Laor, Wolman, & Cohen, 2001). Furthermore, a higher risk of
life threat, family problems and child characteristics (i.e; age, gender) are linked to a moderate
increase to PTSD symptoms in children who have experienced trauma (Fairbank et al., 2006).
In a study by Vernberg, Silverman, LaGreca and Princetein (1996) children who had
experienced more loss and trauma were more likely to develop PTSD. In another study done
during the war in Sarajevo, children between the age of 7-15 who had experienced more
family losses and deprivation in food and housing more often developed PTSD (Husain et al.,
1998)
Researchers are also trying to find the factors that make some children resilient to
traumatic stress reactions (Hughes, Graham-Bermann, & Gruber, 2001). Researchers have
found many different types of resilience factors such as; high IQ, having the ability for
emotional regulation, having social support by close and caring adults, believing in oneself
and that the child trust the safety of the situation (Harris et al., 2006). Research aimed at
finding resilience factors in children who have experienced community violence, found three
main factors, parent support, school support and peer support (Lynch, 2003). Resilience
changes over time, and it may be that when children get older they will develop more
resilience (Margolin & Gordis, 2004).
25
knowing how to relate to other people
59
How children react to trauma
According to Dyregrov and Yule (2006) younger children often show less emotional
numbing. Because of this it is more difficult for a small child to meet the avoidance criterion
in the PTSD diagnosis in DSM-IV. After experiencing a trauma children show many different
stress reactions, these reactions may be different due to age and gender. It is very common for
young children to show very open aggression and also engage in repetitive play26. In
preschool children the reaction is less obvious and more closely tied to their parent’s reaction.
It is best if the parents are trying to be as calm as possible as this may make the child feel
more protected and secure (Dyregrov & Yule, 2006). However, anxious parent often have
anxious children. If an anxious person tries to hide their anxiety the child might pick up on it.
In children that are in the age 8 to 10 their reaction to trauma is often very like the
reaction adults will have. These children are capable of understanding more of what have
happened and can see the long term consequences of the situation. There are some gender
differences, girls are often more sensitive to trauma and thus more often develop PTSD, boys
have more behaviour symptoms, such as acting out (Yule, Perrin, & Smith, 1999). In any age
children that experience chronic and/or repeated traumatic situations such as, war or victims
of sexual or physical abuse may develop personality disorders, self harm or suicidal
behaviour, depression or other major psychological problems. Exposure to a traumatic
situation in these important years may even affect the maturation of the central nervous
system (Cohen el al., 2002).
Central discussions
Comments and evaluations
It is very important to get knowledge about this information for helping children, since
knowing about resilience, protective factors, stressors and risk factors public policies can be
changed so children could get help earlier and support should be done to families’ and
children in need. This may for example be done by trying to eliminate risk factors and support
resilience factors (Harris et al., 2006; Hughes et al., 2001). Unfortunately many psychologists
are unaware of the severe damage trauma can have on very small children, and how trauma
26
Such as drawing the event many times
60
and violence can stunt the developmental growth and many children are never diagnosed
(Stein et al., 2001; Burns et al., 2004). This is especially for children who grow up in foster
care, which may experience much domestic violence or other traumas. More research in this
area needs to be done.
Treatments for children
Cognitive-behaviour therapy is the most used type of therapy for children who have been
traumatized, and this is also often recommended (American Academy of Child and
Adolescent Psychiatry, 1998). The strength in this therapy is its strong empirical support both
for children and adolescents with PTSD. Also CBT can be tailored for the specific problem
the child has. CBT for children diagnosed with PTSD involves many different parts, such as;
skills training, psychoeducation, cognitive coping, stress management, muscle relaxation,
thought stopping, exposure exercises, and relapse prevention. Furthermore, it is beneficial if
parents are included in parts of the therapy with the child (Cohen & Mannarino, 1993; Cohen
et al., 2000). Here follows some different types of therapy that can be used with children who
suffers from PTSD or who have experienced a trauma. Secondly, the research that supports
these treatments is discussed.
Parental training
Parental training is very important in the treatment of small children, but for older children
and teenagers this is not as important. Parental training is mainly psychoeducation, behaviour
modifications and exposure based interventions. In psychoeducation, parents learn about how
children will react after a trauma and which symptoms they may have. Behaviour
modifications teach the parents how they can manage their child’s behaviour better. This also
helps the parents in working with the therapist so they can help their child with things they
have learned in therapy. During the exposure based module parents may discuss their feelings
about their child and the trauma (Cohen et al., 2000).
61
Exposure based techniques
Exposure techniques are often used with adults who suffer from PTSD (Foa, Dancu, &
Hembee, 1999). Children who suffer form PTSD symptoms are now also treated this way
(Deblinger, Heflin, 1996; Deblinger, Lippman, & Steer, 1996). During exposure based
techniques it is important that the child feels safe. The patient is asked to remember the feared
situation or stimuli and to stay in the situation for a while so that the traumatic stress reaction
will be extinguished. There are many types of exposure techniques that have been used on
children. During gradual exposure, the child is asked to verbally express which things that the
child experienced as the worst part, and the clinician helps the patient to process common or
small elements of the traumatic situation (Cohen & Mannarino, 1993). When this therapy
proceeds the child learns not to fear the stimuli and different implementations may be used
such as; drawing, writing, using tapes or acting out the trauma. When the child learns how to
better cope with the trauma, he or she is encouraged to express more about the trauma and
feared stimuli (Saxe, MacDonald, Ellis, 2007).
In imaginal flooding therapy the child is asked to imagine a specific detail from the
trauma, whilst the clinician overlook the child’s personal experience of distress (Saigh et al.,
1996). The theory behind exposure interventions propose that if patients reexperience
traumatic situations or stimuli during therapy, the feared memories will no longer be linked to
anxiety reactions.
Cognitive techniques
Cognitive-behaviour therapy in the treatment of PTSD originates from schema and
information-processing theories (Smith, Perrin, & Yule, 1999). Schema theory holds that,
changes in behaviour may be caused by influencing experiencing and consequences. In
comparison information-processing theory holds that “cognitions drive behaviour and
cognitions and therefore altering cognitions can lead to changes in behaviour, as well as in
affect” (Ehntholt & Yule, 2006, p. 1203). When using Cognitive-behavioural techniques with
children both theories are influenced, and both behavioural techniques and cognitive
techniques are used. Different techniques are used such as problem-solving strategies,
behaviourally based exposure techniques and cognitive techniques to change error in thinking.
62
Cognitive therapy can be used to challenge and change thoughts that sustain anxiety responses
(Resick & Schnicke, 1992). This type of therapy is very helpful when used to change
cognitive errors and to improve the child’s coping skills. Children with a traumatic past often
suffer from cognitive distortions, like self blame, survivor guilt and/or over generalization of
the traumatic experience.
One very useful tool for this is Cognitive coping, a technique developed by Deblinger
and Heflin (1996) from Beck’s (1976) cognitive therapy for depression. Cognitive coping is
tailored especially for children with PTSD symptoms, and teaches them about the link
between maladaptive automatic thoughts, negative emotions, and dysfunctional behaviour.
Furthermore, cognitive coping teaches the child to emotion regulate by at the same time shift
negative cognitions and understand the effect on behaviour (Saxe, MacDonald, Ellis, 2007).
Much new research have examined the effect Cognitive behaviour therapy has on
children with PTSD. CBT has been proved effect full in a range of different participants from
adult refugees (Paunovoc & Öst, 2001) to torture victims (Basoglu, Ekblad, Bäärnheilm, &
Livanou, 2004). Treatment with CBT and medication has shown to be effect full for adult
refugees (Otto et al., 2003). Most of these studies support CBT as the best treatment for
children who suffer from PTSD. Some of these studies are explained here.
Saigh (1987a, 1987b, 1987c, 1989) made an important gift to the child PTSD literature
with his single-case studies about Lebanese war victims. The participants were children 10-14
years old and Saigh used imaginal or in vivo flooding therapy as treatment. The children filled
in a self-report PTSD, anxiety and depression scales as outcome measure. These showed that
the participants experienced less PTSD symptoms, like nightmares, startle response,
avoidance, concentration problems, memory problems, anxiety, depression or guilt (Saigh et
al., 1996). These studies are the only ones done on flooding therapy and PTSD symptoms in
children. These findings support the hypothesis that flooding therapy will also be very useful
in children, however new research needs to be done with a larger sample size and with
different types of trauma (Saxe, MacDonald, Ellis, 2007).
In another study by Celano, Hazzard, Webb and McCall (1996) they compared CBT
with supportive unstructured psychotherapy. The participants were 36 children between the
age of 8 and 13, who had been sexually molested. The girls were randomly assigned into two
groups and treated with one of the therapy types. After the treatment sessions, children in the
CBT groups showed an improvement in PTSD symptoms. However, participants in the
experimental group did not improve. This study has some limitations which should be
63
considered; the sample size was small, 35% of the participants never completed treatment and
there were no after assessment of the symptoms (Saxe, MacDonald, Ellis, 2007).
Another study also by Deblinger and colleagues (2004) compared trauma-focused
CBT with child-centered therapy. The participants were 203 sexually molested 8-14 year olds
who had been diagnosed with PTSD. 79% of the participants were girls, 60% European
Americans, 28% African Americans and 4% Hispanic Americans. The control therapy, childcentered therapy is a therapy form that works by building a strong alliance with the parents
and child by active listening, reflection, empathy and discussion of feelings.
The results of this study showed that in comparing trauma-focused CBT with Childcentered therapy the children who received CBT improved much more in PTSD-symptoms,
depression, behaviour problems and shame. Parents in the CBT group also showed
improvement in depression, distress, and support of their child and in their child rearing.
There is many different strengths in this study, the large sample size, the fact that the
participants have different nationalities and also that structured diagnostic interviews were
used (Cohen, Deblinger, Mannarino, & Steer, 2004).
Group cognitive-behaviour therapy
Group CBT is also often used with children, and have shoved very good results (Chemtob,
Nakashima, & Carlson, 2002). Because more children can be treated in shorter time this is a
very cost effective treatment. Group CBT is similar to normal CBT with children, it also
contains cognitive and behavioural parts, like; psychoeducation, cognitive therapy, exposure
exercises, and relapse prevention (Saxe, McDonald, & Ellis, 2007). The purpose of this
therapy is to teach the children to incorporate traumatic cognitions with their self-concept by
using group exposure exercises and cognitive exercises. Here follows some examples on
research done on the effect of group CBT.
Stein and colleagues (2003) made a randomized, controlled study about group CBT
used for traumatized children in schools. The participants were 116 students in the 6th grade,
the children were from the inner-city and from lower socioeconomic status families.
Furthermore, these children have experienced different types of trauma. The children were
randomly assigned to different groups, one with a treatment of group CBT with 10 sessions
and one wait-list group, who would get therapy later. Three months after the group CBT, the
children who had early treatment still showed low PTSD symptoms, depression and
64
psychosocial dysfunction. This shows how well group CBT works even in a school setting
(Saxe, McDonald, & Ellis, 2007).
This study is important because it is the only one of its kind, were the children have
been randomized and a controlled study of a group CBT has been used on children who have
experienced community violence (Stein et al., 2003). The strengths of this study is that
manualized treatment protocols and standardized outcome protocols was used. The weakness
is that no diagnostic PTSD interview was used, there were no control group who received a
different treatment and the follow up period is only three months. It would be interesting to
see how these children feel after one year or longer (Saxe, McDonald, & Ellis, 2007).
Another important study is by March et al., (1998) were a multimodality group CBT
were tried on 14 participants between the age of 10 and 15. This therapy is conducted during
18 weeks in a school situation and with alone “pullout” sessions to help children with specific
problems. The sample consisted of 67% females, 47% European Americans and 41% African
Americans. The children had experienced a lot of different traumas such as; vehicle accidents,
severe storms, major health problem, gunshot injury and fires. All children improved
dramatically in all symptoms of PTSD, anxiety and depression. Furthermore, after 6 months
follow up the children kept improving (Saxe, McDonald, & Ellis, 2007).The strengths of this
study is that diagnostic interviews were used, and standardized measures were conducted
before and after therapy. The limitations are the small sample size, no control group and that
children with major behaviour problems were excluded (Saxe, McDonald, & Ellis, 2007).
These studies support the hypothesis that group CBT should improve the symptoms
for children with PTSD. However, much more research about group CBT in children needs to
be done, to make sure that treatments will be improved and more proof for the effects are
needed. The study by Stein et al., (2003) is important, but more studies where there is a
difference in the participants (age, culture, gender) and were the children have been exposed
to different types of trauma is needed (Saxe, McDonald, & Ellis, 2007).
Central discussions
Comments and evaluations on therapy for children
The strength of cognitive-behaviour therapy and exposure therapy are their strong empirical
support both for children and adolescents with PTSD. These therapies reduce symptoms of
PTSD, and help the child to look at life in more positive ways which will help with
65
confidence, and an increased sense of control (Nader, 2001). Also CBT can be tailored for the
specific problem the child has.
However, there is a problem in that we do not know as much about treatments for
children as we need to. For example; why some children recover while others do not. Also, if
there is a “best fit” among therapists and children. There also lacks longitudinal studies on
children who have been treated, to evaluate if they are symptom free as adolescents and
adults. The difficulty with treating small children is that their expression on how they feel
after therapy is more difficult to assess in comparison to adults or adolescents, and they may
vary over time. This may be influenced by parents, expectations, development in maturity or
treatment (Nader, 2001).
There needs to be a development in new methods to recognize detailed characteristics
of the child, how they experience trauma and to assess how trauma and treatment affects the
child in the long term. We need to find out more about the relationship between a child’s
history (i.e., attachment, family), PTSD symptoms (i.e., changed mood) or aspects of the
trauma (i.e., duration) or other facts. If clinicians will be able to find and assess these facts
over time, we may improve treatment and what traumatized children need (Nader, 2001).
Main point

CBT is the type of therapy that is mainly used with traumatized children.

Cognitive and exposure therapy will lessen symptoms of PTSD, it may also help the
child to look at life in more positive ways which will help with confidence (Nader,
2001

CBT for children are similar to CBT for adults. However there are some differences
for example: parental training is often a part of CBT for small children.
66
Summary and challenges for the future
I have in this thesis discussed causal risk factors for PTSD. Even if researchers have identified
these factors, the underlying causal mechanisms may still not be completely understood.
According to Kraemer and colleagues (2001), new research should look at not only
identifying risk factors, but also finding the risk mechanisms that underlie associations
between risk factors and outcomes. For example: lack of social support is a causal risk factor
for PTSD, however researchers are not sure what type of causal mechanism through which
social support is connected to PTSD. It may be that people with more social support are the
ones who have more and better recourses that protects against PTSD (Friedman, Keane,
Resick, 2007). To improve research more longitudinal studies needs to be conducted,
including repeated assessment of important variables over time. This type of research is more
expensive, but is important to further our knowledge about risk factors for PTSD.
The recent theories27 described in this thesis have been developed by clinical
researchers who also work with treating patients with PTSD. Because of this, these recent
theories much better explains how and why CBT and exposure therapy work, in comparison
to older theories. These theories are also backed up by research. However, these theories have
limitations and further research needs to be done. For example: Brewin’s dual representation
theory focuses mainly on memory and emotion, other symptoms of PTSD such as emotional
numbing can not be explained by this theory, while emotional processing theory focus mainly
on diminishing fear (Brewin and Holmes, 1993).
As mentioned earlier, in the field of treatments for PTSD, further research needs to be
conducted to explain why so many people do not recover after treatment with CBT and
exposure therapy. Furthermore, to find out why so many participants drop out of treatment.
Conclusion
In this thesis we have discovered that what happens to a person and how a person reacts
before, after and during a trauma (i.e., negative thoughts, coping strategies, mental defeat)
will have a large impact on if a person later develops PTSD. Some even argue that these
factors will be of greater importance than the severity of the trauma itself (i.e., Brewin, 2003).
27
Emotional processing theory, Brewin’s dual representation theory, Ehlers and Clark’s cognitive theory.
67
It may be that, PTSD develops because of psychological and biological vulnerabilities, but
also experiencing high stress and characteristics of the event are important (part 2). This may
be part of the answer to why some people seem to be “immune” to PTSD, while others have a
higher sensitivity to this disorder. Risk and resilience factors are important because they may
help the clinician to quickly make a judgement who may naturally recover, or who will
recover more quickly. They may also be part of the answer to why only about 50% of
participants recover after treatment with CBT and exposure therapy. The problem with these
studies is that the results are rather modest, so a strong conclusion can not be drawn.
The second question discussed in this thesis is: how do clinicians manage the
difficulties related to the treatment of an adolescent or a child suffering from PTSD, and what
is the best treatment according to empirical findings? To be able to answer this, different
theories are discussed (part 3), these theories are discussed because they are the foundation of
well documented treatments that are discussed in part 4. However, one limitation with these
theories is their focus on PTSD as a DSM IV disorder. People that have experienced trauma
may not meet the DSM-IV criteria, but may still have one or two of these symptoms. This
means that we can not be sure how these theories and therapies work for these people.
The empirical research supports the hypothesis that Cognitive-behaviour therapy and
exposure therapy is useful for treatment of PTSD, both for adolescent and children (part 4 and
5). Even if these are the treatments that obviously work, for at least a part of the patients.
Why exposure therapy work is still not completely clear. Different theorists propose different
explanations, as we have seen in part 3. For example: in emotion processing theory Foa and
colleagues propose that there is a fear network that needs to be modified so that things that
once feared no longer is. While according to learning theorists exposure work because of
habituation of classically conditioned fear responses. Some researchers have even found that
expectancies can have an effect on exposure treatments. In a study by Sothworth and Kirsch
(1988) participants were randomly put in three groups and given 10 identical in vivo exposure
sessions , one group were they were told exposure was part of treatment, one group were they
were told exposure was part of getting reliable assessment and one control group. Even if both
groups improved in their fear against spiders, the first group could travel twice as far from
home before getting scared in comparison to the first group. This show how important it is as
clinicians to explain why a type of therapy is important.
Patients who suffer from PTSD today will have a much better chance at receiving a
good science based treatment today than they did 25 years ago. We know much more about
this disorder today than we used to, in this way the research about trauma and PTSD have
68
been very important. However, we need to be careful not to make similar mistakes as in the
past, and in some years we may realise that there are some problems with the therapy we use
today.
69
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Appendix
Biological changes that are caused by trauma
During the last fifty years there has been much progress in the understanding of the
neurobiological basis of fear and anxiety. Researchers have found that specific neurochemical
and neuropeptide systems play a part in how a person reacts in a fear or anxiety producing
situation. It seems that long-term dysregulation of these systems may add to the cause of
anxiety disorders, such as PTSD. Studies have also shown that there are “genes that underlie
the neurobiological disturbances that increase vulnerability to anxiety disorders, including
PTSD” (Friedman, Resick, Keane, 2007, p. 151)
Studies done on rats showed that their hippocampal volume became smaller after a
stressful situation (Sapolsky, 2000; Watanabe, Gould, & McEwen, 1992). These findings
influenced new studies on humans and their reactions after trauma. According to Bremner and
colleagues (1995) war-related PTSD was found to cause 8 % reduction in the hippocampus as
seen by magnetic resonance imaging (MRI) in comparison to people who have not been in the
war or experienced trauma. However, this is only an estimate since they did not measure the
hippocampal volume before the war. These findings were later confirmed in similar studies
(Gurvits et al., 1996; Stein, Koverola, Hanna, Torchia, & McClarty, 1997). Victims that had
PTSD after childhood sexual or/and physical abuse also showed a decrease in hippocampal
volume (see figure, p. 156, Handbook of PTSD). Furthermore, Bremner and colleagues
(2003) found a larger loss of hippocampal volume (18%), in patients who have been abused
as children and who had major depressive disorder (MDD), in comparison to patients who
suffered only from major depression. In this study age, race, education, brain mass and
alcohol use was controlled for. The smaller hippocampal volume is only seen in adults with
chronic PTSD, children will not be affected (Bremner et al., 2005).
However, other studies have not found any decrease in the hippocampus in Holocaust
victims in comparison to Jewish people who had not experienced any trauma. However, very
few survived the Holocaust and they were probably very young when they experienced the
trauma this may have had an impact on the findings (Golier et al., 2000). In a very large study
conducted on 44 abused children with PTSD compared to 61 children without PTSD, found
that there was a significant reduction in intracranial and corpus callosum volume but there
was no reduction in hippocampus (DeBellis et al., 1999). There may be many reasons why
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these studies have found such different results. It may be because of differences in the trauma
(sexual, abuse, witnessing violence, car accidents, war etc), how long the trauma was (from
survivors of war to one accident), severity of the trauma and when the trauma happened (in
childhood or as an adult). Other reasons may be comorbid conditions such as depression or
alcohol problems (Dunman, Mahlberg, Nakagawa, & D’Sa, 2000). In a study about the
hippocampus, researchers found that if patients with major depression used antidepressants
this would protect against hippocampal volume loss (Neumeister, Wood, et al., 2005). Newer
twin studies in PTSD have just begun to show how different the loss of hippocampal volume
may be due to genetic factors in patients with PTSD.
Other brain differences have been found to be linked to PTSD. Many functional
imaging studies have found an association between abnormalities in the amygdala and PFC in
victims suffering from PTSD. Scientific literature has found that unpleasant and traumatic
experiences in early development may later lead to an increased hypothalamatic-pituitaryadrenal (HPA) sensitivity in adulthood. Researchers are not sure if this means that patients
with PTSD have higher central sensitivity to “stress” levels of hydrocortisone in comparison
to patients without PTSD. Other studies have shown that, if a patient with war-related PTSD
is shown traumatic pictures the right part of their amygdala will be triggered (Rauch et al.,
1996; Shin et al., 1997) in comparison to traumatic sound, this will trigger the left part
(Libertzon et al., 1999). However, later studies have been unable to replicate these results
(Bremner, Staib, et al., 1999).
As seen earlier, researchers have established that specific neurochemical and
neuropeptide systems play a part in how a person reacts in a fear or anxiety producing
situation. However, there is much research that needs to be done in this area, and researchers
have not yet found which possible function that receptors and transporters have in regulating
neurochemical functions significant in PTSD, for example serentonin. New research has
looked at the genetic predisposition to find out the transmitter synthesis and release in healthy
people and people with anxiety disorders. The aim is to find out why some people seem to
have a genetic vulnerability to stress disorders, and this may also lead to new insight into
which processes that cause stress-related disorders such as PTSD. The purpose of all this
research is to find new and better treatment options for PTSD sufferers (Friedman, Resick,
Keane, 2007).
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