Week 7 - PTSD

Dissociation in PTSD?

Dissociative symptoms most commonly encountered in trauma include:

• Emotional numbing

• Derealization

• Depersonalisation

• Out of body experiences

• They are related to the severity of the trauma, fear of death and feeling helpless

  • Reflects a defensive response related to immobilisation (freezing)

  • Peritraumatic dissociation: When the symptoms occur in the course of the traumatic experience - predictor for later PTSD

What processes are disturbed in PTSD?

• Memory

• Attention

• Cognitive affective reactions

• Beliefs

• Coping strategies

• Social support

What is unique to PTSD

The unusual and inconsistent memory phenomena entered on the event itself and the recruiting of a variety of dissociative responses

What is the stress response theory (Horowitz) -early theory

2 responses:

1. Outcry at the realisation of trauma

2. Then trying to assimilate the new trauma information with prior knowledge

   • Leafing to a period of information overload - unable to match thought and memories of trauma with the meaning before the trauma

   • Psychological defense mechanisms come up to avoid memories

   • The fundamental need to reconcile new and old information means that trauma memories will actively break into consciousness (intrusions, flashbacks)

   • Oscillation between avoidance and intrusions of the trauma

   • Does not account for multiple factors though (environment etc)

What is the lang’s fear network approach in PTSD?

Frightening evenness were represented within memory as interconnections between nodes in an associative network

• A fear memory consisted of interconnections between different nodes representing 3 types of propositional information:

  • Stimulus information about the traumatic event (sounds)

  • Info about the persons emotional and physiological response to the event

  • Meaning info - primarily about the degree of threat

• Cognition and affect are integrated without an overall response program designed to rapidly escape or avoid danger

• PP with anxiety disorder have unusually coherent and stable fear memories - easily activated by stimulus elements that may be ambiguous but bear resemblance to memory

• When fear network is activated the person experiences the same physiological reactions & tends to make meaning judgments that accord with the original memory

• Chemtob et al.:

• Fear network is permanently activated causing them to function in a survival mode that was adaptive during the trauma

• Which is why persistent reecperiencuing and high levels of arousal occur in PTSD

What do Foa et al say about fear network?

Violates formerly held basic concepts about safety

Event leads to a kind of representation in memory that is different

• E.g. Attack in alley:

  • Activates alley node, fear node, and nodes representing behavioural and physiological responses that were stronger tam the connections of alley node and other emotions and response nodes that were formed before while walking in alleys

• Now there will be a large number of environmental cues that cause the network to be activated

• Fear networks in PTSD are characterised by strong response elements

• Network has low threshold of activation

• Some elements in the fear network remain intact post exposure

What are cons of the fear network models?

• Does not explain how memory can produce rapid responses but at the same time be disorganised and contain gaps

• Does not distinguish between flashbacks and ordinary trauma memories or account for the wide range of other post trauma emotions and beliefs in PTSD

• Old memories may remain intact and that the fear reactions are inhibited by the creation of new memories

What is the anxious apprehension model?

• Inclusion of cognitive factors that occur after the trauma and produce a feedback cycle of anxious apprehension

• Focus attention for information about emotional alarms and associated stimuli

What are the early PTSD theories?

1. Social-cognitive theories: How trauma breaches existing mental structures and on innate mechanisms for reconciling incompatible information with previous beliefs

2. Conditioning theories: Learned associations and avoidance behaviour

3. Information-processing theories: Encoding, storage and recall of fear inducing events and their associated stimuli and responses

Recent theories - Emotional processing theory (For & Rothbaum):

Ptsd arises when traumatic experiences overwhelm and individuals normal coping mechanisms

• Leading to the formation of dysfunctional cognitive structures or schemas

• Schemas consists of maladaptive beliefs about oneself, world others

• These are reinforced by negative appraisals of responses and behaviours during and after trauma

• Exposure therapy! Promotes the integration of fragmented memory structures

• Related to initial fear activation and between-session habituation

SIMPLIFIED EXPLANATZION

• PTSD develops when the emotional processing of a trauma is disrupted which leads to persistent symptoms such as intrusions and avoidance

• Emotional processing of a trauma memory is disruptedbecuase the anxiety is so high & emotions are too overwhelming

• Leading to intrusions because information needs to be processed

memory network simplified

• Memories are organised into networks and each memory is related to stimuli characteristics, response characteristics and meaning

• Trauma can create strong m emotionally charged memories that may be inadequately integrated into a memory network

• When activated a fear network can trigger intense emotional responses

The dual representation theory of PTSD

Unlike fear network theories that suggest traumatic memories are structured similarly to ordinary memories but with heightened emotional elements

• DRT: Traumatic memories are fundamentally distinct and can be represented in 2 seperate memory systems simultaneously

  1. Verbally accessible memory system

     • Narrative, consciously accessible and integrated with other autobiographical memories

     • Information that one has attended to before, during and after trauma and available for deliberate recall

     • Cognitive processes : cog restructuring

  2. Situationally accessible memory system

     • Triggered involuntarily by situational reminders of the trauma

     • Primatrily perceptual and emotional

     • Stores sensory details and bodily responses associated with the trauma but lack verbal coding

     • Less controllable

  3. Theory suggests that PTSD involves 2 processes:

     • The resolution of negative beliefs and emotions associated with the trauma

     • Management of flashbacks

  4. Cognitive restructuring and ET & EMDR

• Requires memory accessibility

What is the cognitive model of Ehlers and Clark PTSD

Model has implication for PTSD treatment: Importance of addressing negative appraisals and maladaptive coping strategies

Provides a framework of how cognitive processes interact with traunmatic experiences to contribute to the develpment and maintenance of PTSD symptoms

Cognitive processes:

• Negative appraisals of the trauma and its consequences

  • Overgeneralisation of: Danger, self blame, feeling of weakness or vulnerability & perceptions of permanent change in oneself or goals

  • Contributes to a sense of current threat either external (safety) or internal (self future)

• Trauma memory

  • Memories are poorly elaborates, lacking a complete context in time and place and are inadequately integrated into autobigraphical knowledge

  • Difficulty in: intentional recall reecperiencingh in the presents lack of connection with other info and easily triggered by similar cues

  • Traumatic memories form string associations leading to perceptiual priming and a reduced threshold for trauma related stimuli

What factors affect the encoding of trauma memory (Ehlers)

Factors during and immediately after the trauma:

• Inability to establish self-referential perspective

• Dissociation

• Emotional numbing

• Lack of cognitive capacity to evaluate aspects of the event accurately

• Maladaptive behavioural and cognitive strategies that PTSD symptoms :

  • Selective attention to threat cues and persistent rumination or dissociative responses

Describe difficulties of Ehlers model

• Complexity of assessing cognitive processing during trauma and the difficulty of distinguishing between different processing styles

Focus on memory disturbance & processing/apraisal - similarities

• EPT: Emphasizes the habituation of fear responses through exposure to traumatic memories.

• DRT: Proposes two memory systems and highlights the important of integrating sensory and verbal memory representations.

• CM: Highlights negative appraisals and cognitive processing styles as central to PTSD.

Acknolöedgment of cognitive aspects - similarities

• EPT: Acknowledges the need for emotional processing and alteration of traumatic memory for recovery.

• DRT: Recognizes the importance of integrating sensory and verbal components of trauma memories.

• CM: Recognizes the role of distorted appraisals and cognitive strategies in maintaining PTSD.

Exposure and treatment goals -similarities

• EPT: Focuses on habituation of fear responses through repeated exposure.

• DRT: Aims to create new memories that compete with original traumatic

  representations.

• CM: Targets modifications of negative appraisals and cognitive restructuring.

• Note. All highlight the incorporation of exposure therapy.

Underlying mechanisms - differences

• EPT: Emphasizes emotional habituation through exposure to trauma memories.

• DRT: Focuses on the integration of sensory and verbal memory representations,

  preventing sensory-based intrusions.

• CM: Targets modification of negative appraisals and cognitive strategies.

Memory system - differences

• EPT: Assumes a single associative network with emotional habituation.

• DRT: Proposes two memory systems.

• CM: Focuses on negative appraisals within an autobiographical memory system.

Differences in treatment technique and focus

0. Treatment Techniques:

   • EPT: Exposure & habituation.

   • DRT: Creating new memories to compete with the trauma memory.

   • CM: Cognitive restructuring and exposure to modify maladaptive cognitions.

     Primary Treatment Focus:

   • EPT: Emotional habituation.

   • DRT: Integrate sensory and verbal memory representations.

   • CM: Modification of negative appraisals and cognitive strategies.

What does complex PTSD ads?

Core criteria

Plus:

. Problems with affect regulation

Self-concept

Interpersonal relationships