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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. PSYCHIATRY 5:7 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 PSYCHIATRY 5:7 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 3 229 © 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. PSYCHIATRY 5:7 230 © 2006 Elsevier Ltd. All rights reserved.