Cognitive Models Of Ptsd

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Information-processing theory has been widely used to understand the development and maintenance of anxiety disorders, including PTSD (Lang, 1979, 1985). This theory suggests that emotions, such as fear, are encoded in memory in the form of networks, where representations of anxiety-provoking events are stored. Fear networks are hypothesized to contain three important types of information: (1) information about the feared stimuli or situation; (2) information about the person's response to the feared stimuli or situation; and (3) information about the meaning of the feared stimuli and the consequent response. Foa and Kozak (1986) posited that the fear networks of individuals with PTSD differ from the fear networks of individuals with other anxiety disorders in three ways. First, the fear network of individuals with PTSD is larger because it contains a greater number of erroneous or inaccurate connections between stimulus, response, and meaning elements. Second, the network is more easily activated by stimulus, response, or meaning elements. Third, the affective and physiological response elements of the networks are more intense. Accordingly, for individuals with PTSD, stimuli reminiscent of the traumatic experience activate the fear network and prompt states of high sympathetic arousal (e.g., increased heart rate and blood pressure, sweating, muscle tension), retrieval of fear-related memories (e.g., intrusive memories, dissociative flashbacks), intense feelings of fear and anxiety, and fear-related behavioral acts (e.g., avoidance or escape behaviors, hypervigilant behaviors).

Chemtob, Roitblat, Hamada, Carlson, and Twentyman's (1988) hierarchical cognitive action theory extended information-processing theory by proposing that for individuals with PTSD, these fear networks (or "threat-response structures") are at least weakly activated at all times, guiding their interpretation of ambiguous events as potentially dangerous. More recently, Ehlers and Clark (2000) proposed a cognitive model of the persistence of PTSD that can also be viewed as an extension of earlier information-processing theories. This cognitive model suggests that PTSD becomes chronic when traumatized individuals appraise the traumatic event or its sequelae in a way that leads to a sense of serious, current threat (e.g., "Nowhere is safe"; "If I think about the trauma, I will go mad"). A second factor proposed by this model as causally related to the persistence of PTSD are changes in autobiographical memory similar to those proposed by earlier information-processing theorists (e.g., strong associations between stimulus and response elements in memory; low thresholds for priming memories associated with the traumatic event).

Although these information-processing theories emphasize the role of fear in the development and maintenance of PTSD, empirical evidence suggests that many PTSD symptoms, including intrusive memories and behavioral avoidance, may be prompted by other strong emotion states. For example, in a longitudinal investigation of crime victims, Brewin, Andrews, and Rose (2000) found that, in addition to fear, emotional responses of helplessness and horror experienced within 1 month of the crime were predictive of PTSD status 6 months later. Further, emotions of shame and anger predicted later PTSD status, even after controlling for intense emotions of fear, helplessness, and horror. Similarly, Pitman, Orr, Forgue, Altman, de Jong, and Herz (1990) found that combat veterans with PTSD who listened to individualized traumatic scripts reported experiencing a range of emotions other than fear. In fact, veterans with PTSD were no more likely to report experiencing fear than other emotions.

The range of emotional reactions evident in individuals with PTSD suggests the need for a theory of PTSD that includes factors other than purely fear-based information processing. Several social-cognitive theories have been proposed to explain the wide range of emotional reactions reported by victims of traumatic events. Social-cognitive models suggest that traumatic events can dramatically alter basic beliefs about the world, the self, and other people. Accordingly, these models tend to focus on the process by which trauma survivors integrate traumatic events into their overall conceptual systems, or schemas, either by assimilating the information into existing schemas or by altering existing schemas to accommodate the new information (Hollon & Garber, 1988). For example, Janoff-Bulman (1992) focused primarily on three major assumptions that may be shattered in the face of a traumatic event: (1) personal invulnerability, (2) the world as a meaningful and predictable place, and (3) the self as positive or worthy. Although it has been demonstrated that trauma victims have significantly more negative beliefs in these realms than nonvictims (Janoff-Bulman, 1992), this "shattered assumptions" theory does not account for the increased level of PTSD symptomatology observed in individuals with a history of traumatic events prior to the index trauma (e.g., Nishith, Mechanic, & Resick, 2000), individuals whose assumptions presumably had already been shattered. A second schema-based social-cognitive model (McCann, Sakheim, & Abrahamson, 1988) proposed five major dimensions that may be disrupted by traumatic victimization: safety, trust, power, esteem, and intimacy. McCann and colleagues hypothesize that for each of these dimensions, schemas may be disrupted either in relation to the self or to others. This theory suggests that difficulties with psychological adaptation following a traumatic event may result if previously positive schemas are disrupted by the experience or if previous negative schemas are seemingly confirmed by the experience.

In an attempt to reconcile the information-processing theories with the social-cognitive theories of PTSD, Brewin, Dalgleish and Joseph (1996) proposed a dual representation theory of PTSD. This theory suggests that memories of a traumatic experience are stored in two ways. Some memories of the experience are referred to as "verbally accessible" memories. This term denotes information the individual attended to before, during, and after the traumatic event (e.g., response and meaning elements) that received sufficient conscious processing to be transferred to long-term memory. In theory this information can be deliberately retrieved from memory. other memories are referred to as "situationally accessed" memories. These memories contain extensive nonconscious information about the traumatic event that cannot be deliberately accessed or easily altered. Dual representation theory also proposes two types of emotional reactions: primary emotions conditioned during the traumatic event (e.g., fear) and secondary emotions that result from the meaning of the traumatic event (e.g., anger, shame, sadness).

Brewin and colleagues suggest that successful emotional processing of a traumatic event (i.e., "completion/integration") requires the activation of both the verbally accessible memories and the situationally accessed memories. During activation of these memory components, resolution of schema conflicts can occur through a conscious search for meaning.

As an extension of these cognitive theories of PTSD, cognitive therapies for PTSD are designed to address cognitive variables as factors that contribute to the development or persistence of PTSD. It is important to note that cognitive therapy is an umbrella term that captures a variety of strategies that are derived from a rich theoretical literature, not simply an added skill included in an otherwise complete treatment. The conceptualization behind these interventions is that an approach that elicits memories of the traumatic event and then directly confronts maladaptive beliefs, faulty attributions, and inaccurate expectations may be more effective than exposure therapy alone. Although imaginal exposure activates the memory structure of the traumatic event and facilitates habituation, it does not provide explicit direction in correcting misattributions or other maladaptive beliefs. Thus, cognitive behavioral therapies for PTSD often supplement exposure with some type of cognitive intervention, most often cognitive restructuring. The technique of cognitive restructuring involves identifying and challenging thoughts that are maladaptive in specific situations. This type of cognitive restructuring is often more present-centered, focusing on "here-and-now" cognitions that impact mood and functioning. In contrast, other types of cognitive interventions may address more general trauma-focused themes, rather than challenging only those thoughts that occur in specific situations. These interventions may examine the traumatic event itself or beliefs about the event. Alternatively, these interventions may address meaning elements of the traumatic events (e.g., tying the event into the meaning of other life events) or underlying dimensions that the trauma impacts (e.g., safety, trust, power, esteem, and intimacy). Further, cognitive therapies can also expand the range of emotion states (beyond fear) that can be targeted in treatment. The inclusion of other emotion states in treatment, including shame, anger, and helplessness, is essential due to their implication in the development and persistence of PTSD.

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How To Win Your War Against Anxiety Disorders

How To Win Your War Against Anxiety Disorders

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