PTSDPTSD

Anushka PaiAnushka PaiTyler DavisTyler Davis

Darrell WorthyDarrell WorthyCindy StappenbeckCindy Stappenbeck

Clinical Factors of PTSDClinical Factors of PTSD

• Rexperiencing symptoms– Intrusive memories– Nightmares

• Protective reactions– Emotional numbing– Amnesia– Cognitive avoidance

• Arousal symptoms– Startle response– Hyper vigilance

• Negative emotions & cognitions– Sadness– Anger– Guilt

Typical characteristicsTypical characteristics

• Typically characterized by an alternation between re-experiencing and avoiding

• Re-experiencing is rapid and spontaneous, vivid, and arousing– Different than normal LTM retrieval in that emotions

are felt in original intensity– May be able to dispassionately discuss traumatic

experience, but still experience trauma related emotions when cued

• Occurs in 25-30% of the population given a traumatic experience

• Decreases over time, but can last up to 40 years

PTSD and Stress ResponsesPTSD and Stress Responses

• Can be explained somewhat in terms of stress responses within the normal range of human experience

• Bereavement– Bowlby’s Attachment Theory– Parkes Psycho-Social Transitions

• Does not account for all aspects of PTSD such as negative flashbacks, startle responses, and high physiological arousal. Can’t explain individual differences.

• Do you think that the differences between PTSD and these general models of responses to stressful events could be related to differences between the stress inducing stimuli, rather than differences in cognitive architecture for handling different types of stress?

Influences on the development and Influences on the development and time course of PTSDtime course of PTSD

• Object exposure (how close were you to the trauma?)

• Levels of social support

• Locus of control (internal vs. external)

• Do you think the locus of control is another example of how our authoritarian ego is actually a safety mechanism?

ComorbidityComorbidity

• 80% of PTSD sufferers have a comorbid disorder– Commonly

• Somatization• Psychosis• Anxiety disorder• Depression

• Shares features of comorbid disorders, but cannot be explained by them

Cognitive Biases in PTSDCognitive Biases in PTSD

• Increased skin conductance for combat related words in PTSD vets vs controls– Are normal people appropriate controls for this?

• Slower in stroop task with trauma related words with personal relevance

• Difficulty retrieving specific memories to cues• Judge negative events as more probable in the

future than controls• PTSD itself cannot be explained by comorbid

disorders, however do you think that most or all of the cognitive biases can be?

Trauma Processing and Trauma Processing and Dual Representation Dual Representation

TheoryTheory

Dual Representation TheoryDual Representation Theory

Conscious ProcessingConscious Processing

• Verbally Accessible Memories (VAMs) – can be consciously retrieved from the store of autobiographical knowledge

• E.g. – “I remember losing a finger in the hot-dog cooker”

• Conscious processing of the accident• May have selective recall – anxiety

increases attentional selectivity and decreases short-term memory capacity

Non-conscious processingNon-conscious processing

• Situationally Accessible Memories (SAMs)- not accessed consciously; may be accessed automatically when the person is in a context where the physical features or meaning are similar to that of the trauma situation

• Hormonal effects of trauma may diminish neural activity in areas associated with conscious processing – motor aspects represented in analogical codes

SAMsSAMs

• This picture could induce a situationally induced memory in a person who has suffered hot dog machine trauma

• The four finger hands could make SAMs even more likely to be activated

Emotional ProcessingEmotional Processing

• Activation of SAMs to aid the process of readjustment

• Conscious attempt to search for meaning and make judgments about cause and blame

• Editing of VAMs to bring perceptions of the event into line with prior expectations

• Need to consciously reassert perceived control• Need to prevent the continued automatic

activation of SAMs• This processing is necessary for overcoming

trauma

Endpoints of Emotional ProcessingEndpoints of Emotional Processing

• How can completion/integration be distinguished from premature inhibition of processing?

• How can we be certain that traumatic memories will not resurface in the future?

Premature inhibitionPremature inhibition

• Dual representation theory distinguishes between verbally and situationally accessible knowledge

• Authors propose that trauma processing can be prematurely inhibited

• What is the right amount of processing?• Should patients dwell on what happened

to them – could it make things worse?• Are these good recommendations?

Overview of persistent PTSDOverview of persistent PTSD

• Pre-trauma Variables

• Cognitive processes during Trauma

• Memory for Trauma

• Appraisals-perception of current threat

• Strategies to control threat and symptoms

Ehlers and Clark (2000)Ehlers and Clark (2000)

Pre-trauma VariablesPre-trauma Variables

• Prior Beliefs (Positive or Negative)

• Previous traumas

• Coping style

Cognitive processes in traumaCognitive processes in trauma

• Conceptual vs. Data driven

• Influenced by– High arousal and fear– Duration and predictability– Perception of control– State factors– Low intellectual ability

Memory for traumaMemory for trauma

• Reexperiencing

• Strong S-S and S-R associations

• Strong perceptual priming

• Poor elaboration and incorporation

Appraisals of traumatic eventAppraisals of traumatic event

• Overgeneralize from event– FEAR

• Overestimate probability of another trauma– FEAR

• How they felt/behaved during trauma– SHAME

Appraisals of trauma sequelaeAppraisals of trauma sequelae

• Interpretations of common symptoms

• Interpretations of others’ reactions

• Interpretations of consequences in other domains

Maladaptive strategiesMaladaptive strategies

• Strategies are meaningfully linked to appraisals

• Maladaptive because– Directly produce PTSD symptoms– Prevent change in negative appraisals– Prevent change in the nature of trauma

memory

Maladaptive Strategies Cont.Maladaptive Strategies Cont.

• Thought Suppression• Selective Attention to threat cues• Safety Behaviors• Trying not to think about the trauma• Avoidance of reminders• Rumination• Dissociation when reminded of trauma• Alcohol or substance use

PTSD TreatmentPTSD Treatment

Putting Trauma in the PastPutting Trauma in the Past

• Memory needs to be integrated into person’s experience to reduce problematic reexperiencing

• Appraisals of the trauma need to be modified

• Avoidance techniques and safety behaviors need to be eliminated

Assessment & Treatment RationaleAssessment & Treatment Rationale

• Attempt to assess coping strategies, what they avoid, how they deal with intrusions, what their fear is about dwelling on trauma

• These identified to use in later treatment• Reexperiencing symptoms are isolated

memory fragments triggered by matching cues– Experienced as if happening in the “here and

now” because they are not integrated into other autobiographical info

Treatment ComponentsTreatment Components

• Thought suppression causes more of the unwanted thoughts– Instructed to accept intrusive thoughts

• Education

• Reclaim one’s former life

Treatment ComponentsTreatment Components

• Reliving Trauma– Make image realistic including thoughts and

feelings as well as what was happening– Verbally describe event in present tense– Therapist uses questions to keep client

focused on feelings and thoughts– Patients rate distress at different points– Cognitive restructuring used to change

problematic thoughts & beliefs about event

Treatment ComponentsTreatment Components

• Reliving (cont.)– As therapy progresses, narrative tends to become

more coherent• Memory loses the “here and now” quality

– Works by facilitating elaboration of the trauma memory

– Facilitates retrieval of elements of the trauma memory difficult to otherwise access

– Verbalization of visual and sensory cues may make it more difficult to retrieve original sensory impressions from memory

Treatment ComponentsTreatment Components

• In vivo exposure– Revisiting the site of event– Engage in feared/avoided behaviors to obtain

disconfirming evidence

• Imagery Techniques– Useful in changing meaning of the trauma

memory– Allows patients to explore consequences of

actions not taken

Treatments Not Covered in ArticleTreatments Not Covered in Article

• Eye Movement Desensitization

• Stress Inoculation Training– Muscle relaxation– Breathing control– Role Playing– Thought Stopping