Download Psychology and cognitive processing in post-traumatic disorders

History, Epidemiology, Treatment
Psychology and cognitive
processing in post-traumatic
disorders
Cognitive features in DSMIV-TR diagnostic criteria
for PTSD
Trauma
Experiencing, witnessing or confronting actual or threatened
death or serious injury or threatened physical integrity
Jamie Hacker Hughes
Response
Intense fear, helplessness or horror
Re-experiencing
Intrusive recollections, including images and thoughts
Distressing dreams
Recurrence (including reliving, illusions, hallucinations and
dissociative flashbacks)
Diagnostic criteria
The term PTSD was introduced into the American Psychiatric
Association’s Diagnostic and Statistical Manual in 1980 and the
definition has since been refined into the current DSM-IV1 (and
DSM-IV (TR)) definitions and those in the equivalent ICD-9 and
ICD-10 of the World Health Organization.2 Current diagnostic criteria as set out in DSM-IV require a person to have been exposed
to one or more traumatic events where they felt that their life
or someone else’s was under threat, or that they or others were
going to be injured and where, at some stage, they felt helpless or
terrified. It is the phenomenon of suddenly realizing that one is
going to die or become seriously injured, accompanied by strong
feelings of terror and/or helplessness, which produces the features of PTSD. These symptoms may appear soon after the event
or at some time later (see Table 1).
Diagnostic criteria as set out in DSM-IV require symptoms to
be present for 4 weeks or more before a diagnosis can be made,
with problems emerging before this time being described either
as ‘acute stress disorder’ or what are termed ‘adjustment reactions or disorders’. Not all people suffering from acute stress
disorder, which requires a certain degree of post-traumatic dissociation to be present, go on to develop PTSD, and many later
go on to develop PTSD without prior acute post-traumatic dissociation. If symptoms do not materialize before 6 months then
a ‘delayed onset’ is said to have occurred (and these forms of
PTSD are usually the more difficult ones to treat psychologically)
and if the symptoms last for more than just 1 month, then the
disorder is said to be ‘chronic’.
Avoidance
Cognitive avoidance
Psychogenic amnesia
Increased arousal
Concentration difficulties
Table 1
or ­traumatic event or, less often, as the ­classic ‘flashback’ which,
again, can occur in any one of a number of sensory modalities.
At least one of these symptoms must occur if a ­diagnosis is to
be made.
Avoidance
The second group are symptoms of behavioural or cognitive avoidance (avoiding people, places or activities that remind the client of
the event or making efforts to try to avoid remembering or thinking
about the traumatic event). There is often diminished interest in
activities that the client used to enjoy before the event and sometimes there is a partial or complete inability to be able to remember
some of the details surrounding the traumatic event. There is also
a recent literature on the possibility of people experiencing posttraumatic symptoms following an event such as, for example, a
road accident where there has been a loss of consciousness. Three
symptoms of increased avoidance are required by DSM-IV.
Symptoms
Re-experiencing
There are three types of symptoms with which PTSD sufferers
present in differing combinations and at least one of each, and in
some cases more, must be found before a diagnosis can accurately
be made. The first group of symptoms are re-­experiencing symptoms occurring as nightmares or disturbing dreams, unpleasant
thoughts, emotions or physiological reactions to sights, smells,
sounds or other cues reminding the patient or ­client of the original
Arousal
Thirdly, the changes that occur in the autonomic system after
massive psychological trauma produce a number of symptoms
of increased arousal. People typically report memory difficulties and difficulties in concentrating on, for example, the plot
of a television programme or the thread of a novel. However,
a number of other problems also occur, including sleeping difficulties, increased hypervigilance and startle responses and an
increase in anger control problems. These latter problems are,
again, extremely difficult to treat and often require additional
psychological treatment even after the nightmares and avoidance
have abated. DSM-IV requires at least two symptoms of increased
arousal if diagnostic criteria are to be satisfied.
Jamie Hacker Hughes PsychD CPsychol AFBPsS is a Consultant Clinical
Psychologist and Clinical Senior Lecturer at the Academic Centre for
Defence Mental Health at King’s College London, UK. He graduated
in Psychology from University College London and trained in Clinical
Psychology at the Universities of Cambridge and Surrey. His research
interests include the clinical treatment of post-traumatic stress disorder
and the psychological effects of military deployment.
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Impairment
The final requirement is that the patient or client must be ex­­
periencing substantial and significant impairment in one or more
228
© 2006 Elsevier Ltd. All rights reserved.
History, Epidemiology, Treatment
areas of their life as a result of the problems that they are experiencing following their exposure to trauma. These problems may
be occurring in their work, home lives, relationships, leisure
activities or, indeed, in all the aspects of their post-traumatic
life.
Cognitive elements in the origin and maintenance
of PTSD
• Classical and operant conditioning responses
• Fear networks
• Emotional processing
•Dissociation between different types of memory
•Poor elaboration
• Cognitive avoidance
•Negative beliefs and schemas
Theories of PTSD
Psychobiological theories of PTSD are discussed on pages 221–
224.
Cognitive theories of PTSD
Why cognitive theories are necessary: an early psychological
formulation of PTSD derives from Mowrer’s two-stage theory.3
In the first stage, a previously neutral stimulus, perhaps a car
of a certain make and colour, acquires the ability to arouse
fear and anxiety as the result of a traumatic incident occurring
which has involved a car of that colour and make. The second
stage involves the victim learning that if they avoid cars with
these characteristics, the post-traumatic responses otherwise
evoked will be reduced. This theory relies on two basic theories
introduced in the first few weeks of undergraduate psychology
courses, namely the processes of classical and operant conditioning. However, conditioning theory breaks down when one
observes that if the sufferer merely confronts the feared object
time after time there is no reduction in strength and intensity of
symptoms. This is partly because there is no simple association
between just one simple type of stimulus (a car) and one type of
response (extreme fear). Manifold other variables are, of course
involved such as the time of day, the lighting, the weather conditions, the sound of tyres, glass and metal, the bodily sensation of
the impact, the smell of fuel, the taste of blood or whatever. Foa
and Kozak introduced the helpful concept of a ‘fear network’
involving not only all of the above variables but also incorp­
orating the thoughts, emotions and physiological sensations of
the trauma victim.4 In order to achieve full resolution, therapy
must involve re-exposure to as many elements of the network
as possible, paying particular attention to the role of cognitions
and cognitive responses, which are often the key to symptom
maintenance.
Table 2
the ­process of recording material in autobiographical memory as
having been disturbed by strong associative memory and poor
elaboration. Ehlers and Clark see PTSD as being maintained by a
number of subconscious cognitive strategies involving, for example, ­cognitive avoidance. It is a classic phenomenon that thought
suppression serves only to increase the frequency and intensity
of the memory being suppressed (see, for example, Shipherd and
Beck7) rather than the opposite. Try not to think of a yellow
hippopotamus for a few moments and this phenomenon will
become clear!
The other element of Ehlers and Clark’s theory that is important, however, is that it stresses the importance of beliefs. It was
Janoff-Bulman who initially proposed that it is the shattering of
previously held beliefs and assumptions (about personal safety,
the honesty and reliability of others, etc.) that is the most significant effect of trauma and that the task of post-trauma therapy is
to help the sufferer to rebuild or modify those beliefs.8 Cognitive
theory holds that it is the persistence and strength of victims’
negative beliefs and schemas about themselves, the world and
others that predicts the subsequent persistence of PTSD.9,10 All
of the above elements are summarized in Table 2.
Cognitive treatments for PTSD
The primary recommended psychological treatments for PTSD
are cognitive behaviour therapy (CBT) and eye movement desensitization and reprocessing (EMDR), both cognitively based treatments (see Table 3).11
Developments in cognitive theory of PTSD: Brewin et al. have
produced an extremely helpful theoretical account of how the
phenomena observed in PTSD might result in an imbalance
between two putative forms of memory which they describe as
situationally accessible memory (SAM) and verbally accessible
memory (VAM).5 They argue that flashbacks are accounted for
by all the situational (visible, audible, tactile, olfactory, gustatory, etc.) elements of the traumatic memory being recorded
in SAM and that, for resolution to occur, these elements must
be connected to the verbal and cognitive elements accessible
through VAM. Flashbacks, they argue, result from dissociation
between the two types of psychological information that have
been encoded in each store.
Ehlers and Clark developed Clark’s influential model of panic
into a theory which posits that PTSD results from the patient
processing the memories of their past trauma such that they
feel that they continue to be under serious threat.6 The similarity between their theory and Brewin’s is that they, too, see
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Examples of cognitively based treatments for PTSD
Cognitive therapy,
focused on:
Eye movement desensitization
and reprocessing
Exposure to intrusive thoughts
and images, especially ‘hot
spots’
Challenging of underlying
and maintaining beliefs,
assumptions and schemes
Desensitization to recurrent
images and thoughts
Installation of adaptive
alternative cognitions
Table 3
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© 2006 Elsevier Ltd. All rights reserved.
History, Epidemiology, Treatment
CBT has traditionally been carried out by clinical psychologists and
behavioural nurse therapists, but is increasingly now also being
taught to psychiatrists. Building upon the cognitive theories for
PTSD described above, CBT involves relaxation training, cognitive
and in vivo exposure and, most importantly, cognitive processing
and restructuring with the aim of modification of underlying beliefs
and thoughts and the reduction of cognitive avoidance strategies.
4Foa E B, Kozak M J. Emotional processing of fear: exposure to
corrective information. Psychol Bull 1986; 99: 20–35.
5Brewin C R, Dalgleish T, Joseph S. A dual representation theory of
posttraumatic stress disorder. Behav Res Ther 1996; 103: 670–86.
6Ehlers A, Clark D M. A cognitive model of posttraumatic stress
disorder. Behav Res Ther 2000; 38: 319–45.
7Shipherd J C, Beck J G. The role of thought suppression in
posttraumatic stress disorder. Behav Ther 2005; 36: 277–87.
8Janoff-Bulman R. Shattered assumptions – toward a new psychology
of trauma. New York: The Free Press, 1992.
9Dunmore E, Clark D M, Ehlers A. A prospective investigation of the
role of cognitive factors in persistent posttraumatic stress disorder
(PTSD) after physical or sexual assault. Behav Res Ther 2001; 39:
1063–84.
10Scher C D, Resick P A. Hopelessness as a risk factor for posttraumatic stress disorder symptoms among interpersonal violence
survivors. Cogn Behav Ther 2005; 34: 99–107.
11National Institute of Clinical Excellence (NICE). Post-traumatic stress
disorder (PTSD): the management of PTSD in adults and children in
primary and secondary care. London: NICE, 2005.
EMDR involves imaginal therapeutic exposure to as much as possible of the material encoded within the fear structure achieving
both in-session and between-session reduction and habituation of
the fear response together with substituting unhelpful self-referent
cognitions and beliefs with ones that are more adaptive and which
will help the client to achieve the goal of post-traumatic growth.
Conclusion
Psychological processes, and in particular cognitive processes,
have a key role in the development and maintenance of PTSD. By
understanding current theorizing about these processes, clinicians
may be helped to appreciate the crucial role of cognitive treatments
in the amelioration and hopeful resolution of the very distressing
and disabling symptoms that develop in those unfortunate enough
to have been exposed to severe psychological trauma.
◆
Further reading
Friedman M J. Post traumatic stress disorder: the latest assessment
and treatment strategies. Kansas City: Compact Clinicals, 2003.
(A condensed practical guide to assessment and medical and
psychological treatment of PTSD.)
Van der Kolk B, McFarlane A C, Weisaeth L. Traumatic stress: the effects
of overwhelming experience on mind, body and society. New York:
Guilford, 1996.
(A comprehensive text covering theory, classification,
developmental issues, memory and an authoritative section on
treatment.)
Yule W, ed. Post-traumatic stress disorders: concepts and therapy.
Chichester: Wiley, 1999.
(A look at PTSD from a predominantly psychosocial perspective.)
References
1American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 4th edn. Washington, DC: APA, 1994.
2World Health Organization. The ICD-10 classification of mental
and behavioural disorders: clinical descriptions and diagnostic
guidelines. Geneva: World Health Organization, 1992.
3Mowrer O H. On the dual nature of learning – a reinterpretation
of ‘conditioning’ and ‘problem-solving’. Harv Educ Rev 1947; 17:
102–48.
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© 2006 Elsevier Ltd. All rights reserved.