ArticleLiterature Review

Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther 38: 319-345

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Posttraumatic stress disorder (PTSD) is a common reaction to traumatic events. Many people recover in the ensuing months, but in a significant subgroup the symptoms persist, often for years. A cognitive model of persistence of PTSD is proposed. It is suggested that PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat. The sense of threat arises as a consequence of: (1) excessively negative appraisals of the trauma and/or its sequelae and (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualization, strong associative memory and strong perceptual priming. Change in the negative appraisals and the trauma memory are prevented by a series of problematic behavioural and cognitive strategies. The model is consistent with the main clinical features of PTSD, helps explain several apparently puzzling phenomena and provides a framework for treatment by identifying three key targets for change. Recent studies have provided preliminary support for several aspects of the model.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Trauma memories associated with PTSD elicit a 'here and now' quality (Ehlers & Clark, 2000). Cognitive models suggest that trauma memories in PTSD lack context and are poorly integrated into autobiographical memory, rendering emotional and perceptual aspects of the memory more prominent and non-volitional (Brewin, 2014;Ehlers & Clark, 2000). ...
... Trauma memories associated with PTSD elicit a 'here and now' quality (Ehlers & Clark, 2000). Cognitive models suggest that trauma memories in PTSD lack context and are poorly integrated into autobiographical memory, rendering emotional and perceptual aspects of the memory more prominent and non-volitional (Brewin, 2014;Ehlers & Clark, 2000). As such, greater recall of sensory and perceptual details and heightened negative emotionality measured by negative emotion word usage are associated with greater PTSD symptom severity and/or PTSD diagnosis (Crespo & Fernández-Lansac, 2016). ...
... Guided by findings from the trauma literature, our objective was to characterise PTSD-associated linguistic expressions in nontrauma narratives that are related to conceptualizations of PTSD focused on cognitive styles characterised by negative thinking and appraisals (Ehlers & Clark, 2000). Specifically, we examined objective scoring protocols quantifying affective content (i.e. ...
... About 16% of traumaexposed children and adolescents develop posttraumatic stress disorder (PTSD) (Alisic et al., 2014). To explain why some, but not all, develop persistent reactions after trauma, cognitive theories of PTSD suggest that psychological adjustment is affected by the way the individuals interpret and give meaning to the potentially traumatic event and their reactions to the trauma (Dalgleish, 2004;Ehlers & Clark, 2000). According to Ehlers and Clark's cognitive model of PTSD (2000), maladaptive appraisals such as 'I will never get over this' play a key role in the development and maintenance of posttraumatic stress reactions (PTSR). ...
... Experiencing more types of PTEs was significantly associated with higher levels of both types of maladaptive appraisals in the terror-exposed sample, a finding that echoes previous studies in the field Ponnamperuma & Nicolson, 2016). Ehlers and Clark (2000) suggest that exposure to several potentially traumatic events can reactivate memories and emotional responses from previous events and give additional negative meaning to the trauma exposure, such as 'I am the type of person that brings out the worst in people' (Ehlers & Clark, 2000). Again, we did not find a significant association between the number of PTEs and the level of maladaptive appraisals in the clinical sample. ...
... Experiencing more types of PTEs was significantly associated with higher levels of both types of maladaptive appraisals in the terror-exposed sample, a finding that echoes previous studies in the field Ponnamperuma & Nicolson, 2016). Ehlers and Clark (2000) suggest that exposure to several potentially traumatic events can reactivate memories and emotional responses from previous events and give additional negative meaning to the trauma exposure, such as 'I am the type of person that brings out the worst in people' (Ehlers & Clark, 2000). Again, we did not find a significant association between the number of PTEs and the level of maladaptive appraisals in the clinical sample. ...
Article
Full-text available
Background: Maladaptive appraisals, such as thoughts about experiencing a permanent and disturbing change and about being a fragile person in a scary world, are associated with posttraumatic stress reactions (PTSR) for trauma-exposed children and adolescents. Less is known about what puts young people at risk for developing such appraisals, and the differential relationship between the types of appraisals and PTSR. Objective: The primary aim was to examine the role of age, gender and exposure to potentially traumatizing events (PTEs) for the levels of maladaptive appraisals. The secondary aim was to investigate the association between the levels of maladaptive appraisals (appraisals of a permanent change and appraisals about a scary world) and PTSR. Methods: We investigated these aims in two samples: survivors after the terror attack at Utøya island in Norway in 2011 (N = 165, mean age 17.65, SD = 1.19) and adolescents referred to treatment after mainly interpersonal trauma (N = 152, mean age 15.08, SD = 2.18). The aims were investigated using linear regression and partial correlation. Results: In the terror-exposed sample, female gender was significantly associated with higher levels of scary-world appraisals, witnessing or learning that someone close were exposed to physical violence was significantly associated with more permanent-change appraisals, and a higher number of PTEs was significantly associated with higher levels of both types of appraisals. For the clinical sample, we found no significant associations between exposure to PTEs, gender, age, and the level of maladaptive appraisals. Both types of maladaptive appraisals were highly associated with PTSR in both samples, and there was no significant difference in the strength of the associations between the types of appraisals and PTSR. Conclusions: The results have implications for identifying adolescents at risk for developing harmful maladaptive appraisals. Both scary-world appraisals and permanent-change appraisals were strongly associated with PTSR in both groups of trauma-exposed adolescents.
... According to the cognitive model of PTSD, excessively negative appraisals of the trauma and/or its sequelae can induce significant feelings of threat in individuals, exacerbating PTSS (Ehlers & Clark, 2000). CSR is a positive form of self-cognition. ...
... Conversely, USR involves excessive preoccupation with traumatic events, resulting in heightened emotional distress and self-critique among individuals affected by trauma. Such persistent negative emotions and cognitive responses pose ongoing threats to individuals, thereby exacerbating PTSS (Ehlers & Clark, 2000). Recent studies also show that CSR is a negative predictor of PTSS (Chi et al., 2021;Kearney et al., 2013) and USR increases PTSS (Hoffart et al., 2015;Liu et al., 2023). ...
... According to the cognitive model of PTSD, current threats, especially negative emotions, act as crucial bridges linking negative cognition and PTSD (Ehlers & Clark, 2000). Individuals with higher levels of USR often perceive themselves as responsible for traumatic events and exhibit elevated self-criticism regarding their behavior and personal standards. ...
... Cognitive-behavioral models may help understand the links of AISA with various negative emotional outcomes. The cognitivebehavioral model of posttraumatic stress disorder posits that trauma survivors' negative, internal, stable appraisals about the cause (e.g., blaming their own character) and subsequent effects of trauma (e.g., fearing of social judgment), and their maladaptive (e.g., avoidance) coping, may underpin the development of posttraumatic stress symptoms (Ehlers and Clark, 2000;Budden, 2009). From a cognitive perspective, negative, character-based appraisals may also be relevant for depressive symptoms that develop following trauma exposure (Clark and Beck, 2010), and rumination and worry about such appraisals, thought to be a strategy to avoid aversive emotions (i.e., avoidance coping), may be relevant for general anxiety symptoms arising following trauma (Rutter and Brown, 2017). ...
... Aligned with cognitive-behavioral models of trauma, selfblame is higher among AISA survivors (particularly women) compared to survivors of sexual assault not involving alcohol (Ehlers and Clark, 2000;Littleton et al., 2009). However, these studies did not distinguish behavioral self-blame, which targets specific actions (e.g., drinking the day of assault), from characterological self-blame, which targets dispositional, stable, character traits (e.g., being too trusting; Janoff-Bulman, 1979). ...
... However, these studies did not distinguish behavioral self-blame, which targets specific actions (e.g., drinking the day of assault), from characterological self-blame, which targets dispositional, stable, character traits (e.g., being too trusting; Janoff-Bulman, 1979). Given characterological self-blame appraisals are perceived as unchangeable, they may predict more negative emotional outcomes following AISA than behavioral self-blame (Ehlers and Clark, 2000). Accordingly, self-blame failed to significantly mediate the association between AISA and posttraumatic stress symptoms in a two-wave longitudinal study when characterological and behavioral self-blame were undifferentiated (Blayney et al., 2016). ...
Article
Full-text available
Introduction Alcohol-involved sexual assault (AISA) survivors who were drinking at the time of the assault may be at risk of internalizing victim-blaming myths and stigma. Cognitive-behavioral models posit the link between AISA and negative emotional outcomes may be explained through maladaptive appraisals and coping – i.e., characterological and behavioral self-blame, shame, low self-compassion (i.e., high self-coldness, low self-caring), and fear of self-compassion. Methods Using a cross-sectional design and community sample of younger adults (N = 409 Canadians, M = 28.2 years old, 51.3% women), we examined these mechanisms’ unique effects in mediating the associations between AISA and posttraumatic stress, general anxiety, and depressive symptoms, respectively. Results In terms of gender differences, AISA was more common, self-coldness higher, and general anxiety symptoms more frequent in women, and fear of self-compassion was higher in men. Using structural equation modeling that controlled for gender and the overlap between outcomes, shame emerged as the strongest mediator linking AISA with all emotional outcomes. Fear of self-compassion also partially mediated the AISA-posttraumatic stress symptom association, self-coldness partially mediated the AISA-general anxiety symptom association, and characterological self-blame fully mediated the AISA-depressive symptom association. Conclusion Avoidance-based processes, ruminative−/worry-based cognitions, and negative self-evaluative cognitions may be distinctly relevant for AISA-related posttraumatic stress, general anxiety, and depressive symptoms, respectively, after accounting for the overarching mediation through shame. These internalized stigma-related mechanisms may be useful to prioritize in treatment to potentially reduce AISA-related negative emotional outcomes, particularly for AISA survivors with posttraumatic stress, general anxiety, and/or depressive symptoms.
... There are several theoretical explanations which point to the importance of social support in buffering the risk of PTSD. Appraisals are central to theoretical explanations of the development and maintenance of PTSD, and one hypothesis is that social interactions may impact cognitive appraisals about the trauma, self and the world (Ehlers & Clark, 2000). Indeed, a recent review indicated that parents influence the way children appraise a traumatic event, encouraging trauma discussion or avoidance . ...
... By this we mean that PTSD symptomatology was improved for children and young people in the trials included, regardless of its small effect upon social and interpersonal domains. This supports cognitive models of PTSD, which implicate the importance of other psychological processes, such as trauma appraisals and avoidance (Ehlers & Clark, 2000). That said, this review reveals that young people may continue to have challenges with social functioning, or continue to feel that they do not have adequate support despite undergoing therapy. ...
... A study conducted in China found that higher trust in the government caused lower perception of possible earthquakes and lower preparedness (Han et al., 2017). Some studies reported that risk perception (Han et al., 2011;2017), severe disasters (Frost et al., 2024), and the gap between public expectations and disaster relief capacity (Han, Liu, et al., 2021;Han, Wang, et al., 2021) all undermined trust in authorities, and led to PDS (Bonfanti et al., 2023;Ehlers & Clark, 2000;Thoresen et al., 2018;Yang & Bae, 2022). Therefore, effective disaster response by government during disasters is considered good emergency policy and increases public trust (Cafferata et al., 2021;Frost et al., 2024;Kim, 2019), which reduces the damage and PDS caused by the disaster (Bronfman et al., 2016;Lin et al., 2007). ...
... The present study also showed that increased trust reduced most of the anxiety symptoms in the Kahramanmaras earthquake survivors. This result is in line with Ehlers and Clark (2000), Bonfanti et al. (2023), Thoresen et al. (2018) and Yang and Bae (2022). ...
Article
Full-text available
This article examines the moderated mediation role of trust inauthorities in the direct and indirect effects of earthquakeexposure on psychological distress symptoms (depressive, anxietyand stress symptoms) through somatic fear (sleep loss andincreased heart rates). Convenience and snowball samplingmethods were used to collect survey data from 552 adultparticipants (221 men, 331 women) living in the earthquake zone.The independent variable is earthquake exposure, the mediatingvariable is somatic fear, and the moderating variable is trust inauthorities (emergency plans and strategies, government policies,and media information). Factor analysis using structural equationmodelling confirmed one factor for fear of earthquake and trustin authorities and three factors for symptoms of psychologicaldistress. Regression results showed that disaster survivors hadlow trust in authorities in Turkiye. Mediation and moderatedmediation results based on the bootstrap method showed thatsomatic fear mediated the effect of earthquake exposure ondepressive symptoms, anxiety symptoms and stress symptoms,and trust in authorities moderated the indirect effects ofearthquake exposure on stress symptoms through somatic fear.Increased trust in authorities in Turkiye would alleviatepsychological distress symptoms among the Kahramanmarasearthquake survivors
... We also found that nodes exhibiting high IEI predominantly fell within the domain of PTSD symptoms, with avoidance symptoms displaying the highest IEI, followed by hyperarousal and intrusive symptoms. These symptoms are consistent with previous cross-sectional network analysis findings in PTSD (Brewin, 2014;Ehlers & Clark, 2000;Schnyder et al., 2015) and are further supported by the results of this longitudinal network analysis. The centrality of avoidance symptoms possibly initiated by the negative emotions and cognitions associated with traumatic events (Schlechter et al., 2022). ...
... For instance, there may be in-strength connections to experiences like 'I found myself acting like I was back at that time' (Greene et al., 2020). These sensations, coupled with a reduced capacity for contextual memory integration, may lead to a perception of immediate threat, prompting subsequent avoidance responses aimed at mitigating overwhelming trauma-related sensations (Ehlers & Clark, 2000). Furthermore, research has identified variations in the manifestation of core PTSD symptoms across distinct phases following traumatic incidents. ...
... Posttraumatic stress disorder (PTSD) is a complex psychiatric condition characterized by avoidance, negative changes in thinking and mood, alterations in physiological arousal and emotional reactions, and intrusive and distressing memories that replay elements of traumatic events, leading to profound emotional distress and impairment in daily functioning (American Psychiatric Association, 2013). Previous research has predominantly focused on the impact of real-life traumatic events on the development of intrusions and subsequent PTSD (Ehlers & Clark, 2000;James et al., 2016;Ozer et al., 2003). ...
... Besides the important contribution of conditioning processes to the aetiology of audiovisual and pain intrusions, cognitivebehavioural models also indicate that peritraumatic processing plays a crucial role in intrusion formation (e.g. Ehlers & Clark, 2000). This is supported by research in trauma-exposed persons (Ozer et al., 2003) as well as by analogue trauma studies using highly aversive film-clips in a laboratory setting, which allows investigating processes during traumatization, not being possible in retrospective clinical studies (Holmes & Bourne, 2008). ...
... Explanatory models of different therapeutic approaches (e.g. cognitive therapy [CT], cognitive behavioural therapy [CBT], prolonged exposure [PE], eye movement desensitization and reprocessing [EMDR]) see these cognitions as important factors that maintain PTSD symptoms (Ehlers & Clark, 2000;Foa & Kozak, 1986;Resick et al., 2016;Shapiro & Forrest, 2001). Indeed, the association between trauma-related negative cognitions and PTSD symptoms was found in several studies (overview in Gómez de La Cuesta et al., 2019). ...
... Kumpula et al., 2017;McLean, Yeh, et al., 2015;Zalta et al., 2014), CPT (Schumm et al., 2015), and trauma focussed CBT (Kleim et al., 2013;Zoellner et al., 2011). This in turn is consistent with various established explanatory models of PTSD, in which trauma-associated cognitions play a central role (Ehlers & Clark, 2000;Foa & Kozak, 1986;Resick et al., 2016;Shapiro & Forrest, 2001). However, it should be noted that there are also a few studies, particularly for PE (Hagenaars et al., 2010;McLean, Su, et al., 2015) and CPT (Dillon et al., 2019;Held et al., 2022;Lee et al., 2021), which have not found this temporal connection. ...
Article
Full-text available
Background: The relationship between trauma-related negative cognitions and post-traumatic stress disorder (PTSD) symptoms has been studied frequently. Several studies found a mediating effect of trauma-related negative cognitions on symptom reduction in studies on different psychotherapeutic treatments, however, this relationship has never been studied in imagery rescripting (ImRs) or eye movement desensitization and reprocessing (EMDR). Objective: To analyse the role of trauma-related negative cognitions in the treatment of PTSD due to childhood trauma with EMDR and ImRs. Method: N = 155 patients with PTSD due to childhood trauma aged between 18 and 65 (M = 38.54) participated in a randomized clinical trial and were treated with either EMDR or ImRs in Australia, Germany, and the Netherlands between October 2014 and June 2019. We analysed the relationship between PTSD symptoms (Clinician-administered PTSD Scale for DSM-5, CAPS-5 and Impact of Event Scale revised; IES-R, completed twice for index trauma and for all other traumas) and trauma-related negative cognitions (Post-Traumatic Cognitions Inventory, PTCI) using Granger Causality analyses with linear mixed models on person-centered variables. Assessments were conducted pre-treatment, post-treatment (12 sessions in 6 weeks), eight weeks post-treatment, and one year after the pre-treatment assessment. Results: Changes in negative cognitions (PTCI) preceded changes in PTSD symptoms (unidirectional) as measured by the CAPS and the IES-R for index trauma. For the IES-R related to all other traumas, a unidirectional relationship was found in which changes in PTSD symptoms preceded changes in negative cognitions. No moderating effect of treatment was found. On the level of PTCI subscales only changes in cognitions about oneself preceeded changes in PTSD symptoms. Conclusions: The results support the idea of a general role of trauma-related negative cognitions in the treatment of PTSD. The analyses should be replicated with a higher frequency of assessments.
... Considering the model assumptions, it is essential to examine the factors that hinder the adaptation process to trauma. These factors contain persistent ruminations about an experienced event and difficulties in regulating emotions [4,5]. The concept of emotional processing refers to the process of regulating emotional processing, emotional functions, or emotional regulation successfully, and its purpose is to give meaning to a reformulate trauma-related emotions and traumatic events [6]. ...
... Based on the emotional processing model, there are five groups of emotional processing deficits including avoidance, suppression, ineffective regulation, poor emotional experience, and unprocessed emotional symptoms [8]. According to the model of Ehlers and Clark [5], the cognitive and emotional activities of people in the trauma face are one of the main factors that affect the consequences of experiencing a traumatic event. Based on the available evidence, Efron suggests that problems in the emotional processing of cognitive activities in the form of uncontrollable rumination related to a traumatic event cause PTSD and maintain its symptoms [9]. ...
... The positive role of mental imagery in shaping behaviour has been applied to a variety of contexts, including sports and musical performance (Keller, 2012;Lindsay et al., 2023). In contrast, mental imagery has been implicated in several mental health disorders (Holmes & Mathews, 2010;Ji et al., 2019), such as post-traumatic stress disorder (Ehlers & Clark, 2000), social anxiety (Chapman et al., 2020), suicidal behaviour (Holmes et al., 2007;Lawrence et al., 2021Lawrence et al., , 2023Wesslau et al., 2015;Wetherall et al., 2018), and self-harm (Dargan et al., 2016;Hasking, Di Simplicio, Mcevoy & Rees, 2017;McEvoy et al., 2017). ...
Article
Full-text available
Background Growing evidence suggests that self‐harm‐related mental imagery is involved in the transition from self‐harm ideation to enactment. However, there has been little research on this important phenomenon in adolescent populations. Methods Using an online questionnaire, the frequency, content and impact of self‐harm‐related mental imagery was investigated in a transdiagnostic clinical population of young people with recent self‐harm. Mood ratings were used to assess the impact of completing the questionnaire. Results Fifty‐five young people aged 14–24 years old completed the study. Participants were mostly female (85.5%) and White (87.3%). All but one participant (98.2%) reported images related to self‐harm, with 53 (96.4%) reporting future‐oriented self‐harm images, 53 (96.4%) reporting past‐oriented images, and 52 (94.5%) reporting both. Imagery included imagining self‐harm and particularly dangerous acts (including suicide), specific methods, and the consequences of self‐harm for self and others. Past self‐harm‐related mental imagery was sometimes used to develop future‐oriented self‐harm‐related imagery planning, highlighting the influence of previous exposure to self‐harm. Most participants (N = 45; 88.2%) stated that significant self‐harm‐related mental imagery increased the likelihood they would self‐harm. Stimulation of mental imagery was most frequently reported to be related to dreams about self‐harm (N = 33; 60.0%), and exposure to self‐harm‐related content on social media (N = 32; 58.2%) and in fictional TV programmes (N = 30; 54.6%). There was no significant difference in participants' pre‐ and post‐questionnaire mood ratings. Conclusions Self‐harm‐related mental imagery is commonly experienced by young people who self‐harm and may play a role in ideation‐to‐enactment of self‐harm. Asking about self‐harm‐related mental imagery can be done safely and could be considered for inclusion in routine clinical assessments. Self‐harm exposure and the origins of self‐harm‐related imagery, such as the links with past self‐harm and social media, as well as potential imagery‐based interventions for self‐harm, require further evaluation. A working model of self‐harm‐related mental imagery is presented.
... PTSD A sense of current, serious threat arising from: 1) negative appraisals of the trauma, and 2) memory disturbances with strong associative memories. Often resulting in episodes of re-experiencing the trauma (e.g., flashbacks), hypervigilance, and avoidance (45) Re-experiencing "The bangs and the noises and you think "it's all happening again" (P01) "The more stronger the flashback, the more real the sensations feel to me" (P05) "I dream about someone or something that was associated with it" (P12) "I panicked, and I freaked out, I saw it and I just went into meltdown" (P13) "I'd doze off in the day and wake up screaming" (P14) Avoidance "I won't go near the little camping stove because that's what it that blew up" (P01) "I couldn't even use the oven because the heat would make me physically shake" (P08) ...
Article
Full-text available
Introduction Burns and other injuries requiring plastic and/or reconstructive surgery (BPRS) are lifechanging, often unexpected, and increase the risk of psychiatric morbidity. There are no published studies we are aware of that explores the applicability of psychological models to BPRS patients. Cognitive behavioural therapy (CBT) is the benchmark treatment in mental health but may be less effective in physical health settings. Metacognitive therapy (MCT)can be more effective than CBT in mental health settings and shows promise in reducing anxiety and depression symptoms in people with cancer and cardiac disease. The present study explored the psychological experiences (feelings, thoughts, and coping strategies) of BPRS patients, and whether the concepts underpinning cognitive and metacognitive models can be elicited from these accounts. Method Semi structured interviews were conducted with 11 patients recruited from a BPRS psychology service. Data was analysed using Thematic Analysis. Patients described a range of emotions including low mood, anxiety, anger, guilt, loss, and negative thinking. Results From the perspective of the cognitive model, there were examples of each of 10 pre-specified distorted thinking types (cognitive distortions), and patient talk seemed to fit problem-specific cognitive models. From the perspective of the metacognitive model, all patients described the “cognitive attentional syndrome,” i.e., how they engaged in repetitive negative thinking (worry, rumination) and thought-focused regulation strategies. Patient talk also demonstrated both positive and negative metacognitive beliefs. Conclusion The implications of applying the findings from each model to clinical practice are discussed. The metacognitive model may offer benefits in clinical practice that should be investigated further.
... Research investigating the role of ER flexibility in the development of PTSD may be fruitful in elucidating components of emotion regulation that facilitate recovery. Wellestablished cognitive and cognitive-behavioural models of PTSD consistently identify deficits in emotion regulation as key maintaining factors (Ehlers & Clark, 2000;Foa et al., 1989). Although investigations of ER flexibility in the context of PTSD are in their infancy, key characteristics of PTSD typify ER flexibility deficits, including a limited ER repertoire (marked by an over-reliance on avoidance-based emotion regulation strategies) and limited contextual sensitivity (marked by overgeneralised threat perception and heightened emotional reactivity) (McLean & Foa, 2017;Tull et al., 2020). ...
Article
Full-text available
Purpose Emerging research investigating mechanisms underpinning PTSD has identified emotion regulation (ER) flexibility – the ability to flexibly use ER strategies according to contextual demands – as one promising mechanism. To date, however, no study has investigated whether brief training in ER flexibility can minimise negative affect elicited from evocative stimuli. This study investigated the impact of instructed ER flexibility on emotional responding in probable PTSD. Methods Participants (N = 148) viewed images that differed in negative emotional intensity (high or low). For each image, participants followed instructions to adopt either a flexible or inflexible ER approach through randomisation to either an ER flexible condition or one of three control conditions (Inflexible Reappraisal, Inflexible Distraction, Context Insensitive). In the ER Flexible condition, participants were instructed to switch between distraction and reappraisal according to the emotional intensity of the image. The control conditions required participants to either employ a single ER strategy (Inflexible Distraction and Inflexible Reappraisal) or switch between strategies in a way that did not align with image intensity (Context Insensitive). Negative affect was rated after each image. Results Participants with probable PTSD in the ER Flexible condition demonstrated the lowest levels of negative affect. For participants without probable PTSD, negative affect did not differ between the ER conditions. Conclusions Findings suggest that individuals with probable PTSD benefitted from being instructed in ER flexibility. This finding supports the adaptiveness of ER flexibility and provides a preliminary temporal link between instructed ER flexibility and improved emotional responding for those with PTSD.
... People grappling with major life crises can suffer posttraumatic symptoms, but they can also experience the posttraumatic growth (PTG; Joseph & Linley, 2008). Researchers suggest that the styles of ruminations might be associated with the differences (Benetato, 2011;Ehlers & Clark, 2000). Traditionally, rumination has been defined as the repetitive contemplation of the causes, meanings, consequences, and symptoms of depressive emotions (Nolen-Hoeksema, 1991). ...
... Most trauma theories, such as dual representation theory (Brewin, Dalgleish, and Joseph 1996), the cognitive model of PTSD (Ehlers and Clark 2000) and psychological wellbeing theories (such as the PERMA model, Seligman 2002; psychological wellbeing, Ryff and Keyes 1995) focus on individual responses even when they address collective processes such as appraisal, social support and positive relationships. As such, they do not account for the long-term collective impact of MHRVs, collective processes of meaning-making and coping or shared understandings of justice and justice-seeking. ...
Article
OPEN ACCESS - Research highlights the long‐term collective effects of mass human rights violations (MHRVs) on survivors’ wellbeing. This multi‐method, multi‐context paper combines the social identity approach (SIA), transitional and social justice theories and human rights‐conceptualised wellbeing to propose a human rights understanding of trauma responses and experiences in the context of MHRVs. In Study 1, ethnographic research in four locations in Kosova, 5 years post war indicates that lack of perceived conflict‐related and social justice is experienced as a key contributor to survivors’ individual and collective wellbeing. In Study 2, 61 semi‐structured interviews with MHRVs survivors from post‐war Kosova, post‐conflict Northern Ireland and post‐dictatorship Albania two to three decades post conflict also show that such justice experiences inform wellbeing. These studies illustrate the importance of expanding the SIA to health and trauma theories by taking account of a human rights‐conceptualised wellbeing as well as adopting a holistic analysis of justice perception.
... This may range from a fully controlled mental simulation to an intrusive image which is experienced as involuntary, unwelcome and distressing. Whilst these emotional intrusive mental images are considered the 'hallmark' symptom of posttraumatic stress disorder (Ehlers and Clark, 2000), they are also present in the development and maintenance of a wide variety of other mental health problems (Çili and Stopa, 2015), including social phobia (Hackmann et al., 2000), health anxiety (Muse et al., 2010), and obsessive compulsive disorder (Coughtrey et al., 2015). Such experiences overlap with many of the features of a hallucinatory experience within a psychotic presentation. ...
Article
Full-text available
Background Mental imagery plays a key role in the onset and maintenance of psychological disorders, and has become the target of psychological interventions for the treatment of several anxiety-related conditions. However, there are currently no transdiagnostic measures designed to assess the varied dimensions of mental imagery relevant to psychopathology. Aim To develop and validate a new measure assessing the experiences and appraisals of negative mental imagery. Method The initial item pool was generated through a comprehensive literature review and interviews with subject-matter experts. An online community sample provided data for the exploratory ( n =345) and confirmatory ( n =325) factor analyses. Results The new 16-item Negative Mental Imagery Questionnaire demonstrated four subscales (Intrusiveness, Controllability, Beliefs about Mental Imagery, and Realness). Reliability and validity were good to excellent for both the full- and sub-scales. Conclusions Appraisals of mental imagery captured by the new measure are consistent with previous research on mental imagery and psychopathology.
... One of the most plausible explanations is that exposure-based interventions directly target NA, almost by definition, whereby experiences of mastery and accomplishment during imaginal and in vivo exposure may occur (e.g., Benight & Bandura, 2004) secondarily to fear extinction and decreases in negative emotional responses to trauma cues. Similarly, shifting negative, trauma-related beliefs about oneself, others, and the world may set the stage for the adoption of new, more adaptive, trauma-related beliefs (Ehlers & Clark, 2000;LoSavio et al., 2017). It is also possible that NA no longer interferes with experiences of PA during potentially rewarding experiences (DePierro et al., 2018) or frees up cognitive resources to facilitate greater attention to and processing of rewarding experiences (Litz et al., 2002). ...
Article
Full-text available
Objective: Posttraumatic stress disorder (PTSD) is associated with elevated negative affect (NA; e.g., Badour et al., 2017) and diminished positive affect (PA; Nawijn et al., 2015). PTSD treatments reduce NA (e.g., Jerud et al., 2014), but changes in PA and relationships between changes in affect and PTSD symptoms remain unclear. Method: This study examined changes in PA and NA in adults (N = 130) with PTSD receiving prolonged exposure (PE) or PE plus sertraline as part of a randomized controlled trial (NCT01600456). Participants completed measures of affect (PANAS; Watson et al., 1988) and PTSD symptoms at 10 weekly treatment sessions. Cross-lagged dynamic structural equation models examined associations between session-to-session fluctuations in affect and PTSD. Results: PA increased moderately (d = 0.51) and NA decreased strongly (d = 0.78) across treatment sessions. Within-person fluctuations in PA and NA were generally reciprocal, PAt → NAt+1: effect size (ES) = −0.09, 95% CI [−0.15, −0.02]; NAt → PAt+1: ES = −0.20, 95% CI [−0.28, −0.13]. However, fluctuations in PTSD more strongly predicted next session NA (PTSDt → NAt+1: ES = 0.50, 95% CI [0.38, 0.60]) and PA (PTSDt → PAt+1: ES = −0.26, 95% CI [−0.34, −0.17]) than the reverse. PE augmentation with a selective serotonin reuptake inhibitor did not moderate temporal associations. Conclusions: Prolonged exposure produced substantial improvements in PA and NA. General affective changes may be more a consequence than a driver of PTSD improvement during PE, with improvements in NA and PA potentially linked to the extinction of negative emotional responses to trauma cues and increased engagement with rewarding activities, respectively.
... Irritability refers to a lesser degree of easily annoyed and impatient emotional states, which tends to be an internal experience [48], whereas anger refers to a greater degree of an intense and uncontrollable emotional outpouring of rage, which tends to be an external reaction [48]. The strong correlation between the two may be explained by the fact that an individual's increased sensitivity to violent trauma after experiencing a traumatic event leads to a lower threshold for expressing undesirable emotions, making the individual more irritable; the long-term accumulation of irritability leads to the expression of strong anger [49]. Further, the close association between depression and PTSD may be through the linkage mechanism of more microscopic symptoms, that is, "Suicidality ideation" and "Numbness. ...
Article
Full-text available
Background Horizontal violence can cause serious mental health problems for nurses, particularly anxiety, depression, and post-traumatic stress disorder. However, the intrinsic linkage mechanism between mental symptoms of anxiety, depression, and post-traumatic stress disorder in nurses exposed to horizontal violence is unclear. This study aims to elucidate the characteristics of anxiety, depression, and post-traumatic stress disorder networks among nurses with horizontal violence exposure. Methods Data for this cross-sectional study were obtained from the baseline portion of a short longitudinal survey conducted at four tertiary hospitals in Shandong Province, China. A total of 510 nurses with horizontal violence exposure completed the General Information Scale, the Negative Acts Questionnaire, the Seven-item Generalized Anxiety Disorder Scale, the Nine-item Patient Health Questionnaire, and the Four-item SPAN. The network model was constructed using network analysis. The expected influence and the bridge expected influence of nodes were calculated. The stability and accuracy of the network were estimated. Results The results show that A4 (Trouble relaxing) and P1 (Startle) had the highest expected influence in the network. D9 (Suicidality ideation) and A5 (Restlessness) were the key bridge symptoms. Conclusions “Trouble relaxing”, “Startle”, “Suicidality ideation”, and “Restlessness” are all mental symptoms that need to be urgently improved the most in nurses exposed to horizontal violence. Nursing administrators and policymakers should implement mental health intervention programs for these symptoms as early as possible to maximize nurses’ mental health.
... Studies investigating the motivations behind vengeful behaviour show that people engage in revenge to return what they believe perpetrators deserve, improving their self-esteem, and re-establishing balance or giving 'tit for tat ' (McCullough et al., 2001). Maladaptive coping behaviours, such as persistent beliefs in achieving justice or revenge are documented in the cognitive model of PTSD (Ehlers & Clark, 2000). This supports the theory of revenge documented by various authors (Bies et al., 1997;Bradfield & Aquino, 1999). ...
Article
Full-text available
Background: Prolonged conflicts in the Democratic Republic of Congo (DRC) have caused widespread psychological trauma among civilians leading to maladaptive coping strategies across generations. Despite this occurrence, empirical studies on the prevalence of trauma and its impact on attitudes towards revenge and forgiveness, particularly among the youth, are scarce. This study aims to clarify the relationship between Post Traumatic Stress Disorder (PTSD) symptom severity and the desires for forgiveness and revenge among Congolese adolescents residing in Uganda. Methods: We analysed data from 269 adolescent refugees from the DRC living in the Nakivale refugee settlement in Southwestern Uganda. The assessment included exposure to war-related traumatic events and the MINI-KID for DSM-V PTSD symptom severity. The Heartland Forgiveness and Vengeance Scales measured willingness to forgive and feelings of vengeance. Results: Exposure to war-related traumatic events was notably high in our sample, with severe deprivation of food (260 [97%]), exposure to armed combat (249 [93%]), witnessing bombing, burning, or destruction of houses (245 [91%]), disappearance of family members (239 [89%]), and seeing dead bodies (236 [88%]). PTSD symptom severity was negatively associated with willingness to forgive (b = −0.48; 95% CI −0.71–−0.25; p < .001) and positively associated with vengeance (b = 0.18; 95% CI 0.04–0.32; p = .011). Conclusion: PTSD symptom severity reduces the willingness to forgive and increases the desire for vengeance among adolescent refugees. Mental health clinicians and policymakers should consider addressing maladaptive coping behaviours related to feelings of revenge and unwillingness to forgive in their support strategies for refugees.
... Behavioural theory has been enriched and supported by numerous studies, including the model of PTSD introduced by Ehler and Clark (2000). According to their model, PTSD develops only when individuals perceive the traumatic incident and/or its consequences as a serious threat. ...
Thesis
Full-text available
Since the outbreak of the civil war in Syria, millions of Syrians have sought refuge in neighbouring countries, with Turkiye hosting the largest number of displaced Syrians globally. Among the challenges faced by this population, the prevalence of mental health disorders, particularly PTSD, depression, and anxiety, has become a pressing issue. Therefore, a systematic review was conducted fundamentally to examine the prevalence and correlates of these mental health conditions among externally displaced Syrians. Seventeen studies meeting eligibility criteria were analysed, revealing significantly elevated rates of PTSD (23.26-42.63%), depression (30.29-50.53%), and anxiety (17.66-48.93%) compared to the general population. Despite the effectiveness of various psychological interventions, accessibility to mental health treatments remains limited, especially in post-conflict areas. Narrative Exposure Therapy (NET) has demonstrated success in treating PTSD among refugee populations, yet its application and effectiveness specifically for displaced Syrians remain unexplored. Against the backdrop of a vast number of Syrian refugee population in Turkiye and the dearth of structured mental health interventions, this study aimed to explore the feasibility and effectiveness of implementing NET within the Turkish context. In this vein, a preliminary focus group was conducted to assess potential barriers and contextual challenges to delivering NET in the Turkish setting before the main intervention of NET study. Content analysis of the focus group discussions drew a roadmap for the recruitment and delivery process of the NET intervention. Following the findings of the focus group that suggest inclusion criteria for the recruitment of NET participants, a Single Case AB design study was undertaken, involving three participants, to track changes in PTSD, anxiety, stress, and self- Concept Clarity (SCC) in NET intervention over time. The findings indicate a promising potential of NET in reducing symptoms of PTSD, anxiety, and stress, with notable improvements in SCC observed during the intervention. This pioneering study represents a significant step in addressing the mental health crisis among Syrian refugees in Turkiye. Its findings underscore the urgent need for evidence-based, accessible, and practical psychological interventions to cater to the specific needs of this vulnerable population. Moreover, the study emphasises the critical role of NET outlining context-specific research in informing effective mental health policies and interventions for displaced populations.
... Indeed, according to the cognitive-processing theory of PTSD, a traumatic event will be harder to process or assimilate with prior knowledge if the individual becomes highly stressed and overwhelmed, which is why psychological defense mechanisms are brought into play in order to manage the distress, including denial of the trauma, numbing, flashbacks and nightmares [39]. Ehlers and Clark's cognitive model of PTSD also stresses the importance of the individual's appraisal of the trauma, given that a negative appraisal of the meaning of the trauma can sometimes create a sense of a serious current threat, and an individual can also experience impaired memory encoding during the trauma where the traumatic memory becomes fragmented and poorly integrated into autobiographic memories [40]. ...
Article
Full-text available
Background Community violence exposure (CVE) in adolescence is associated with poorer mental health although the situational factors that may impact on this relationship remain relatively unexplored. The present study aimed to investigate if the degree of perceived stress during CVE has an effect on future posttraumatic stress disorder (PTSD) symptoms in youth, and if this association differs between females and males. Methods Data were analyzed from 760 U.S. adolescents (mean age = 14.00 years), who participated in two surveys, one year apart. Information about CVE (witnessing violence and violence victimization) and the stress severity associated with it was collected in the first survey, whereas data on PTSD symptoms were obtained in the second survey. Generalized Linear Models were used to examine the associations that were also adjusted for ethnicity, age and socioeconomic status. Results The results showed a longitudinal association between CVE-related stress and future PTSD symptoms, with students who had higher levels of perceived stress during CVE (witnessing or victimization) reporting higher PTSD symptom levels subsequently. There was no interaction between sex and CVE-related stress and PTSD symptoms, although females reported more PTSD symptoms. Conclusions The severity of the perceived stress associated with CVE should be regarded as a potentially important prognostic factor for identifying those who might develop PTSD symptoms after CVE and this may facilitate early intervention and treatment for those exposed to community violence.
... It involves the therapist asking the individual to imagine a traumatic memory or aversive event. The therapist then helps the person rewrite it using a safer narrative (Ehlers and Clark, 2000;Ehlers et al., 2005). An example of integration was researched by Kindt et al. (2008) in a sample of 71 participants with chronic PTSD. ...
Article
Full-text available
Background Imagery-focused therapies within cognitive behavioural therapy are growing in interest and use for people with delusions. Aims This review aimed to examine the outcomes of imagery-focused interventions in people with delusions. Method PsycINFO, PubMed, MEDLINE, Web of Science, EMBASE and CINAHL were systematically searched for studies that included a clinical population with psychosis and delusions who experienced mental imagery. The review was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and quality appraisal of all included papers was completed using the Crowe Critical Appraisal Tool. Information from included texts was extracted and collated in Excel, which informed the narrative synthesis of results. Results Of 2,736 studies identified, eight were eligible for inclusion and rated for quality with an average score of 70.63%. These studies largely supported their aims in reducing levels of distress and intrusiveness of imagery. Four of the eight studies used case series designs, two were randomised controlled trials, and two reported single case studies. It appears that interventions targeting mental imagery were acceptable and well tolerated within a population of people experiencing psychosis and delusions. Conclusions Some therapeutic improvement was reported, although the studies consisted of mainly small sample sizes. Clinical implications include that people with a diagnosis of psychosis can engage with imagery-focused therapeutic interventions with limited adverse events. Future research is needed to tackle existing weaknesses of design and explore the outcomes of imagery interventions within this population in larger samples, under more rigorous methodologies.
... A network analysis of PTSD symptoms among adolescents living in conflict-affected areas and yields has also highlighted that intrusion had a significantly high node strength [64]. To explain the emergence of PTSD1, Ehlers and Clark [65] suggested that two key memory processes are involved: perceptual priming and associative learning. Perceptual priming heightens the sensitivity to trauma-cued stimuli by diminishing the perceptual threshold. ...
Article
Full-text available
In the post-pandemic era, psychological traumas have emerged as major mental health issues. However, the post-traumatic reactions and their connections with social-emotional competence among high school students experiencing COVID-19 lockdown have not been adequately explored. This study aimed to reveal the characteristics of their positive and negative post-traumatic reactions, and their connections with social-emotional competence. Network analysis was used on data from 1096 Chinese high school students who experienced COVID-19 lockdown. Measures included the DSECS-S, the PTGI and the PC-PTSD-5. The results revealed that “Valuing life” and “Recalling unwillingly” were identified as core factors of post-traumatic reactions, while “Having close friendships”, “Getting along well with others” and “Respecting others’ emotions” played a bridging role in connecting the communities of social-emotional competence and post-traumatic reactions. This study enriches research on post-traumatic reactions, emphasizing the importance of implementing social-emotional competence programs to tackle mental health crises.
... A CBT intervention for grief that addresses these symptoms is cognitive therapy for traumatic bereavement Murray and El-Leithy, 2023;Wild et al., 2023). This is based on an extension of the cognitive model of PTSD (Ehlers and Clark, 2000) and is supported by research demonstrating that the targets for treatment, namely memory characteristics, negative appraisals and unhelpful coping strategies predict and maintain symptoms of prolonged grief and PTSD following bereavement (e. g., Ehlers, 2020, 2023). Components of treatment, including memory rescripting and imagery conversations with the deceased, have not been examined in adolescents. ...
Article
Full-text available
Grief is highly prevalent in adolescents, however, there have been no studies investigating internet delivered cognitive behaviour therapy for grief in adolescents (ICBT-G-A). In this paper, the co-design of an unguided ICBT-G-A intervention is described, and a protocol outlined for a pilot randomised controlled trial of the intervention. Participants will be randomised to the intervention (delivered via eight modules over a four-week period) or a four-week waitlist control. Intervention participants will complete a follow-up assessment at one-month post-intervention (eight weeks from the pre-intervention assessment). The intervention outcomes assessed at pre-intervention, post-intervention and follow-up include wellbeing and symptoms of anxiety, depression, post-traumatic stress, and prolonged grief. User feedback on experiences and acceptability of the intervention will be sought and feasibility assessed via programmatic data on recruitment and attrition.
... This study is the first within a larger project aiming to evaluate a blended trauma-focused cognitive treatment (bTF-CT) developed for Swedish routine clinical care services. The treatment is based on Ehlers and Clark's CT-PTSD treatment (20) with the accompanying internet-program adapted from the guided internet version of CT-PTSD (14). ...
Article
Full-text available
Introduction Access to evidence-based psychological therapy for posttraumatic stress disorder (PTSD) is limited. Blended Trauma-focused Cognitive Therapy (bTF-CT), merging internet-modules with a few therapy sessions, may be a pathway to enhance treatment access while maintaining the benefits of face-to-face therapy. Objectives This study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness of bTF-CT for PTSD in routine care, as well as the feasibility of assessments and data collection. Method A single-arm design was adopted. bTF-CT was provided to 17 participants across two psychiatric and one primary care clinic. Assessments were conducted pre, during, post and 6-months following treatment. We assessed feasibility and acceptability via self-report questionnaires, retention, and attrition rates. To estimate preliminary treatment effectiveness the PTSD Symptom Checklist (PCL-5) was used to assess PTSD symptom severity. Results Treatment satisfaction was high with a mean score of 28.7 out of 32 on the Client Satisfaction Questionnaire (SD = 3.5). The dropout rate was low, with 88% treatment retention. Program adherence was satisfactory, with scores ranging from 2.13 to 3.13 out of 4 on the internet intervention patient adherence scale. On the PCL-5, 88% made a reliable change, 64% demonstrated a clinically significant change, and the mean change from pre to post was 24 points (d = 2.13). Some negative effects were reported, such as unpleasant memories, feelings, and disrupted sleep, but these were temporary according to symptom scales. Conclusions bTF-CT appears to be acceptable, feasible, and potentially effective when delivered in routine care. A large-scale non-inferiority trial to assess effectiveness compared to a gold-standard treatment is warranted. Clinical Trial Registration Clinicaltrials.gov, identifier NCT04881643.
... Therefore, active cognitive processing is crucial for reformulating new schemas to achieve PTG. Rumination has been identified as a key active mechanism or maladaptive cognitive process in both the maintenance of PTSD [12,33]) and potential development of PTG [9,34]. Shigemoto and colleagues [36] examined post-trauma outcomes for undergraduate students who had experienced a traumatic event within the previous three years. ...
Article
Full-text available
The risk of developing posttraumatic stress symptoms following exposure to traumatic events is well documented, however, emerging research also lends support to the potential development of growth in some people. Rumination and memory have been identified as important factors in post-trauma outcomes, yet, current research in this area is limited, particularly in the context of a multidimensional view of rumination (i.e., intrusive and deliberate rumination) and metamemory beliefs. This study explored the association between rumination styles, beliefs about memory, and posttraumatic stress symptoms and posttraumatic growth. Participants (N = 151) who experienced a traumatic event completed relevant measures online. Path analysis showed that intrusive rumination was significantly related to higher levels of posttraumatic stress symptoms (β = 0.19, p < 0.01), while deliberate rumination was related to higher levels of both posttraumatic growth (β = .52, p < 0.001) and posttraumatic stress symptoms (β = 0.15, p < 0.05). Additionally, negative beliefs about memory were significantly related to higher posttraumatic stress symptoms (β = 0.48, p < 0.001). No significant associations were found for positive beliefs about memory. The findings suggest that rumination may be understood as multidimensional, incorporating both adaptive and maladaptive processes. Further, the present study contributes to the limited literature concerning metamemory beliefs and may provide an increased understanding of factors contributing to stress or growth.
... The concept of emotional processing has been described (Rachman, 1980) as the process by which an emotional disturbance generated by a stressful life event decreases until the person can reach previous functioning. However, when emotional experiences are not fully integrated or processed, this can lead to the return of fears, or the development of obsessions or intrusive thoughts, symptoms that are included in the description of PTSD (Ehlers and Clark, 2000;Brewin, 2001). For this reason, Rachman (2001) proposed the excessive avoidance or rigid and prolonged inhibition of the negative emotional experience as factors that may prevent its reintegration and resolution. ...
Article
Full-text available
This study presents a preliminary analysis of a new instrument oriented at the analysis of processes in EMDR trauma therapy, the Processing Difficulties Scale (PDS). This scale includes 17 items described by experienced EMDR consultants and practitioners as indicative of problems during memory reprocessing. The proposed factorial solution based on four factors explains a total variance explained of 55% and an adequate goodness of fit, based on the proposed indices: RMSEA = 0.07; TLI = 0.91; CFI = 0.95. Table 1 shows the factorial loads for each of the items. The first factor includes 5 items (7, 8, 9, 10, 11), the second factor includes 6 items (13, 14, 25, 27, 28, 31), the third factor includes 3 items (3, 16, 22) and the fourth factor includes 3 items (19, 23, 24). Confirmatory analysis confirms the factorial solution proposed in the exploratory analysis factor and based on four factors with 17 items. The analysis of internal consistency from Cronbach’s alpha and the Omega index shows good internal consistency: Factor 1 (good processing; α = 0.92; ω = 0.94), Factor 2 (lack of generalization and/or absence of changes; α = 0.87; ω = 0.90), Factor 3 (poor emotional processing; α = 0.83; ω = 0.85) an Factor 4 (loss of dual attention; α = 0.82; ω = 0.83). In the case of the total scale, both coefficients exceeded 0.90, with an alpha of 0.92 and an Omega of 0.94. The convergent and discriminant validity criteria were estimated by calculating correlations, exploring the relationship between the factors resulting from the final result, the global severity index (GSI) of the SCL-90 and the level of improvement (NGS). These statistical analyses showed good levels of convergent and discriminant validity for all final factors. The PDS may offer a different perspective to analyze the controversy between clinicians and researchers about the need of a preparation phase in patients with complex early traumatization, dissociative symptoms and/or emotion dysregulation, and the different results in specific research around this topic. Exploring the problems in processing in a transdiagnostic way, in a preliminary analysis, we found that the number of early traumatic events measured with the ACE correlates positively with indicators of a loss of dual attention, while emotional dysregulation measured with the DERS does not predict poor processing. Finally, the dissociation measured with the DES seems to correlate positively with the indicators of a loss of dual attention during processing, not seeming to predict poor processing but did show a negative correlation with the indicators of good general processing. These results partially support the findings of some authors on the involvement of certain variables in the processing of traumatic memories, and it may be interesting to evaluate processing styles and their relationship with various indicators, to develop specific interventions in phase 2 of EMDR therapy, thus improving clinical interventions.
... Som del av implementeringsprosjektet får et utvalg av terapeutene i tillegg tilbud om opplaering i to kunnskapsbaserte behandlingsmetoder for PTSD: Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro & Forrest, 2016) og kognitiv terapi for PTSD (CT-PTSD) (Ehlers & Clark, 2000). Terapeutene mottar tre dagers opplaering i behandlingsmetodene og ti timer veiledning i gruppe. ...
Article
Full-text available
Purpose: The aim of this study is to shed light on how implementation of a new practice in mental healthcare can be carried out. We describe experiences with systematic implementation of treatment methods for post-traumatic stress disorder (PTSD) in outpatient mental healthcare clinics in the Nord-Trøndelag Health Trust (HNT) in 2020–2021. We also examined how many patients were diagnosed with PTSD and how many consultations were given targeting PTSD before, during and after the implementation period (2017–2023). Method: The authors’ subjective experiences with the implementation process were shared and discussed. Two of the authors were implementation facilitators, and one author was a first-level leader in one of the outpatient clinics. Administrative data from the Nord-Trøndelag Health Trust were collected and analysed. Results: The first-level leaders at the four outpatient clinics initiated regular digital meetings where they shared experiences and solved problems during implementation. All employees were involved in the implementation process. A larger percentage of patients was diagnosed with PTSD during the implementation period (12%) compared with the period before (8%) and after (10%) implementation. The same applied to the percentage of consultations for the same patient group (13%) compared with the period before (9%) and after (1%) implementation. Implications: This study gives a practical example of systematic implementation of a new practice in a Norwegian health trust. The study also shows how administrative data can be used in the evaluation of an implementation. Keywords: implementation, PTSD, evidence-based practice, trauma, outpatient mental healthcare
... In addition, while the intervention did not target PTSD symptoms specifically, the shared experience of a physical disability may have enabled some participants to re-evaluate their own experience and the impact it has had. This new information may have reassured them that are "not alone" and bring new meaning to the eventa key step during PTSD treatment (68). ...
Article
Full-text available
Background: Despite growing international attention, there remains an urgent need to develop mental health services within low and middle income countries. The Khmer Rouge period in Cambodia saw the destruction of all health services infrastructure in the 1970s. Consequently, Cambodia has struggled to rebuild both its economy and healthcare system, with the number of qualified mental health clinicians remaining disproportionately low. Resultantly, there is a pressing need to develop low-cost community based alternatives of mental healthcare. Methods: Using a mixed methods design, researchers developed an 8-week peer-led intervention, known as a Friendship Group, for adults with physical disabilities using both face-to-face and online delivery methods. The Wilcoxon Signed-Rank test was used to assess changes in pre-post survey scores and qualitative data was collected in form of five focus groups post intervention. Results: 41 participants were allocated across four Friendship groups – two were online and two face-to-face. Attrition rate was 22% post-intervention (n = 32). ITT analyses showed a statistically significant decrease in psychological distress scores [Z = −3.808, p < .001] from pre [Mdn = 20, IQR = 16.5–25.5] to post [Mdn = 16, IQR = 14–18.5] intervention. A Wilcoxon signed-ranks test also showed a statistically significant decrease in PTSD scores [Z = −2.239, p < .025] from pre [Mdn = 4, IQR = 3–5] to post [Mdn = 3, IQR = 2.75–4] intervention. There was also a statistically significant decrease in worry scores [Z = −3.904, p < .001] from pre [Mdn = 5, IQR = 3.5–6.5] to post [Mdn = 3, IQR = 3–4] intervention. There were no significant group differences between the face to face and online groups. A number of interconnected themes emerged from focus group data (n = 5), these included the mental health benefits of Friendship Groups as conceptualised through knowledge acquisition, skill development and peer support. Conclusions: The Friendship group intervention delivered in both online and face-to-face formats appears feasible and acceptable within the Cambodian context. Initial data revealed positive findings in terms of reduction in psychological distress, worry and PTSD symptoms as well increased feeling as calm.
Article
Introduction and objective: Both the illness itself and hospitalisation due to COVID-19 are potentially traumatic experiences, especially when the course of the disease is severe. Resilience has been identified as a crucial factor in the process of successfully coping with traumatic events and may protect against the development of symptoms of post-traumatic stress disorder. The aim of this study was to determine the role of resilience in the prevention of post-traumatic stress disorder symptoms in patients requiring hospitalisation due to COVID-19. Materials and methods: A total of 138 patients (59 women, 79 men; mean age: 52.34 years; standard deviation, SD = 12.46) hospitalised at the University Hospital in Krakow were included in the study, which was conducted 7–8 months after their COVID-19 diagnosis. The PTSD Checklist for DSM-5 (PCL-5) and the Resilience Measurement Scale (SPP-25) were administered, and stepwise multiple regression analysis was used in the predictive models. Results: A total of 31 participants (22.5%) met the criteria for probable post-traumatic stress disorder symptoms. The study participants were characterised by a moderate level of resilience (5th sten), with women exhibiting lower levels than men. Higher levels of resilience were associated with lower severity of PTSD symptoms. A significant predictor of post-traumatic stress disorder symptoms was “Tolerance for failure and treating life as a challenge”. Conclusions: Resilience has an impact on the severity of symptoms of post-traumatic stress disorder. Specifically, the dimension of “Tolerance” within resilience appears to be an important protective factor against post-traumatic stress disorder symptoms after hospitalisation for COVID-19. Patients hospitalised with severe course of COVID-19 exhibit a moderate level of resilience, with men demonstrating higher resilience levels than women.
Article
Cognitive processing therapy (CPT) is a well‐known trauma‐focused treatment that aims to generate more adaptive posttrauma cognitions and emotions. Changes in cognitions are theorized to be the mechanism by which CPT leads to improvement in posttraumatic stress disorder (PTSD) symptoms. The present study aimed to explore associations between changes in PTSD symptom clusters during CPT. We hypothesized that early changes in negative alterations in cognitions and mood (NACM) would correlate with later changes in other symptom clusters. Data were collected from 296 veterans participating a 7‐week PTSD residential treatment program at a U.S. Veterans Affairs medical center. PTSD symptoms were assessed at pretreatment (Week 1), midtreatment (Week 4), and posttreatment (Week 7). Cross‐lagged path analyses demonstrated that pretreatment‐to‐midtreatment improvement in NACM was correlated with midtreatment‐to‐posttreatment improvement in avoidance, β = .52, though this association was bidirectional, suggesting pretreatment‐to‐midtreatment improvements in either cluster may be correlated with midtreatment‐to‐posttreatment improvements. Similarly, pretreatment‐to‐midtreatment improvement in intrusions, β = .40, and arousal, β = .49, were correlated with later improvement in avoidance, suggesting avoidance may improve after improvement in other clusters. Interestingly, pretreatment‐to‐midtreatment arousal improvement was significantly correlated with midtreatment‐to‐posttreatment NACM improvement, β = .27, though the reverse was nonsignificant, whereas a bidirectional association between arousal and intrusions emerged, β = .34, β = .53. Early changes in arousal were correlated with later changes in several other symptom clusters, whereas other clusters demonstrated bidirectional associations. These results may inform understanding of symptom improvement timing across CPT, which may aid in treatment selection and planning.
Article
Full-text available
Background Trauma films are often used as analogues of potentially traumatic events in experimental research to study trauma exposure under controlled conditions. However, those kinds of trauma films are rarely validated through comparison with neutral films. Also, previous trauma-analogue studies have mainly used self-report measures to assess memory of the film, which are subject to demand characteristics. The objective of this study was to validate the effects of a trauma film compared to a neutral-control film on emotional responses and intrusive memories. We also introduced a novel method of assessing implicit memory, by measuring concept activation in memory. Methods Twenty-two participants watched a trauma film, and 17 participants watched a neutral film. They reported their affective state and intrusions on a 5-minute period, and then over the 6 following days. The activation of concepts was tested with a lexical decision task: negative and neutral targets (words and non-words) related and unrelated to the films were presented, and participants had to judge their lexicality. Results The trauma film increased negative affect and elicited more frequent intrusions than the neutral film. The number of immediate intrusions was strongly correlated with those reported over 6 days. The trauma film elicited faster responses on the film-related words than the neutral film, revealing a greater activation of concepts in memory. Conclusion Results show that this trauma film can be an effective experimental method to induce emotional responses and intrusive memories. The lexical decision task seems to be a promising method to further investigate the role of implicit concepts activation in the consequences of trauma exposure.
Article
The impact of childhood trauma on adolescents’ development is a key topic in social science. Much of the existing literature focuses on its negative consequences, with limited study on its effects on positive social functions, particularly prosocial behavior. This study aims to uncover the link between childhood trauma and prosocial behavior among Chinese adolescents, focusing on how meaning in life and resilience mediate this relationship and how sex and social dominance goals moderate these effects. This study utilized random cluster sampling to survey 659 adolescents (mean age = 15.05, SD = 1.576, 53.6% female) in Huai’an City, Jiangsu Province, China. Data on childhood trauma, meaning in life, resilience, and prosocial behavior were collected through self-reported measures. The data were analyzed through Process Macro Model 4 for mediation effects and Model 8 for moderated mediation in SPSS 26.0. Findings indicated that meaning in life (β = −.042, P < .001, SE = 0.015) and resilience (β = −.071, P < .001, SE = 0.018) partially mediate the impact of the main effect. Social dominance goals reduced the negative effects of trauma on prosocial behavior; higher levels lead to reduced impacts (β = −.173, P < .001, SE = 0.039, t = −4.448). Sex differences also moderated the effect of trauma on meaning in life, with females experiencing a greater decrease in the meaning of life after adversity (β = −.825, P < .001, SE = 0.112, t = −7.372). This research offers new insights into the mechanisms by which childhood trauma affects prosocial behavior and emphasizes the need to consider sex and social dominance goals in trauma interventions.
Article
Full-text available
Purpose of Review We review prevalence, etiology, impact on treatment, and best practices for treatment of posttraumatic stress disorder (PTSD) in a substance use disorder (SUD) treatment setting. Recommendations are given related to screening, assessment, and symptom monitoring. Recent Findings PTSD and SUDs are highly comorbid. This comorbidity is associated with higher acuity, more difficulty completing treatment, and worse prognosis. Integrated treatment is recommended, and trauma-focused psychotherapies combined with pharmacotherapy show particular promise. Summary PTSD is highly prevalent in substance using samples, negatively impacting treatment course and worsening prognosis. This comorbidity has been explained by a variety of models, with self-medication having garnered the most support. Trauma-focused psychotherapies combined with pharmacotherapy demonstrate the most efficacy and are recommended when treating co-occurring SUDs and PTSD. Specifically, prolonged exposure (PE), concurrent treatment of PTSD and SUDs using PE (COPE), and cognitive processing therapy (CPT) have been seen as promising trauma-focused treatments. Investigations into ways to best augment therapy are also underway, both through treatment format and neuromodulation. Several recommendations are given.
Article
Full-text available
Background This study examined the power of theory-derived models to account for the development of PTSD, Complex PTSD (CPTSD), depression, and anxiety in children and adolescents who had experienced a single-event trauma. Methods Children ( n = 234, aged 8–17 years) recruited from local Emergency Departments were assessed at two and nine weeks post-trauma. Data obtained from self-report questionnaires completed by the child, telephone interviews with parents, and hospital data were used to develop four predictive models of risk factors for PTSD, CPTSD, depression, and Generalized Anxiety Disorder (GAD). ICD-11 proposed diagnostic criteria were used to generate measures for CPTSD and PTSD to assess for risk factors and identify the sample prevalence of these disorders. Results At nine weeks post-trauma, 64% did not meet criteria for any disorder, 23.5% met criteria for PTSD, and 5.2% met criteria for CPTSD. 23.9% and 10.7% had developed clinically significant symptoms of depression and GAD, respectively. A cognitive model was the most powerful predictive model, a psychosocial model was weak, and subjective markers of event severity were more powerful than objective measures. Conclusions Youth exposed to single-incident trauma may develop different forms of psychopathology, and PTSD and CPTSD are frequently experienced alongside other conditions. The cognitive model of PTSD shows utility in identifying predictors of PTSD, CPTSD, depression, and GAD, particularly the role of trauma-related negative appraisals. This supports the application of cognitive interventions which focus upon re-appraising trauma-related beliefs in youth.
Article
Full-text available
Background: Dominant models of posttraumatic stress disorder (PTSD) implicate threat-related attention biases in both the development and maintenance of posttraumatic stress symptoms. However, the ability to better understand and modify threat-related attention biases in PTSD has been hampered by the low reliability of attention bias measures more generally. Methods: The current study adopts a new approach to calculate attention bias from a dot-probe task, response-based attention bias (RB-AB) computation, in a sample of 689 individuals reporting significantly elevated PTSD symptoms who participated in a clinical trial of threat-related attention bias modification training. Results: RB-AB is a reliable strategy for deriving threat-related attention bias scores that correlate with both PTSD severity and anxiety. On the other hand, scores from the traditional approach were unreliable and not associated with clinical symptoms. Attention training led to reductions in RB-AB indices of attention bias, but not the traditional index, although attention bias training conditions did not appear to moderate these effects. Conclusions: Taken together, these findings support evidence that threat-related attention biases may be a feature of PTSD and that RB-AB computation is a more reliable and valid approach for studying reaction-time-based attentional processes. Using the RB-AB approach to assess attention bias could allow us to better understand threat-related attention biases in PTSD and to ultimately develop more precise interventions to reduce threat-related attentional biases in PTSD and other disorders.
Article
Attentional bias and deficits in attentional control are associated with posttraumatic stress disorder (PTSD) symptoms. Attention control training (ACT) may address these factors. We reviewed randomized controlled trials (RCTs) of ACT for PTSD to address unanswered questions about ACT's effectiveness, tolerability, and implementation. Studies were included if they were an RCT that used an adult sample, recruited participants with a PTSD diagnosis, and had ACT as at least one treatment arm. The PTSD Trials Standardized Data Repository (PTSD‐Repository) and additional databases were searched to identify PTSD RCTs published through May 2024. Seven studies met the inclusion criteria ( N = 407). The effect size for ACT versus a comparison condition on PTSD symptoms was large, but the confidence interval (CI) overlapped with 0, g = 0.75, 95% CI [‐0.63, 2.12]. The same pattern was observed for attention bias variability, g = 1.04, 95% CI [‐0.90, 2.98]. There was a significant within‐group effect of ACT on self‐reported PTSD symptoms, g = ‐1.43, 95% CI [‐2.83, ‐0.03]. Risk of bias varied, with high risk of bias being primarily due to bias in the measurement of the outcome. These effects should be interpreted cautiously given the significant heterogeneity and wide confidence intervals observed. It remains unclear for whom and under what conditions ACT may be most effective. Future studies should move beyond response time measures, employ an inactive comparator, and examine the mechanism of action to determine whether ACT could be a viable intervention for PTSD.
Article
Background: Little is known about the naturalistic course of posttraumatic cognitions (PTCs) after exposure to a potentially traumatic event (PTE) in children and adolescents. Moreover, previous studies on the longitudinal associations of PTCs with internalising symptoms yielded mixed results. Objective: To explore the naturalistic courses and longitudinal associations of dysfunctional PTCs and functional PTCs with posttraumatic stress symptoms (PTSS), depression, and anxiety. Method: A total of 115 children and adolescents, aged 7–15 years, were assessed within 1 month, 3 months, and 6 months after exposure to an acute accidental PTE. Repeated measures analyses of variance were conducted to capture the naturalistic courses of PTCs and internalising symptoms. Cross-lagged panel analyses were applied to explore the longitudinal relationship between dysfunctional and functional PTCs, along with their longitudinal associations with PTSS, depression, and anxiety. Results: Dysfunctional PTCs and internalising symptoms decreased, whereas functional PTCs increased over time. Dysfunctional and functional PTCs were moderately inversely related, but no significant cross-lagged paths emerged among them. Dysfunctional PTCs were moderately to strongly associated with internalising symptoms, while functional PTCs were weakly to moderately inversely associated with internalising symptoms. Initial PTSS predicted later dysfunctional PTCs (β = .31, p < .05), but not vice versa. Conclusions: Dysfunctional PTCs, functional PTCs, and internalising symptoms were entangled over time. Our findings support the cognitive scar model with initial PTSS predicting later dysfunctional PTCs. Future research complementing between-subject with within-subject analyses could offer additional insights into the longitudinal relationship between dysfunctional PTCs, functional PTCs, and psychological symptoms.
Article
Full-text available
Resolving trauma may contribute to mental health and parenting in mother with histories of childhood maltreatment. The concept of trauma-specific reflective functioning (T-RF) was developed to assess the complexity of thought processes regarding trauma. The study aimed to validate the T-RF scale applied to the Trauma Meaning-Making Interview by examining its psychometric properties, associations with measures of trauma-processing strategies, maternal reflective functioning and mental health (depression and post-traumatic stress disorder [PTSD]), as well as evaluating whether T-RF offered a unique contribution to maternal insightfulness. Good construct validity of the T-RF scale was confirmed in a sample of 112 mothers with histories of childhood maltreatment using an independent coding system of trauma-processing. Better mentalization of trauma was prospectively associated with higher parental reflective functioning and mothers with high T-RF were much more likely to be insightful regarding the child’s mental states than non-reflective mothers and mothers with limited T-RF. The association between T-RF and insightfulness was observed even when controlling for maternal reflective functioning, trauma-processing strategies, maternal education and sociodemographic risk. T-RF was associated neither with depression, PTSD nor the characteristics of trauma. Findings suggest that mentalizing trauma would be an important protective factor in the intergenerational trajectories of trauma.
Article
Full-text available
Recent work on distributed cognition and self-narrative has emphasised how autobiographical memories and their narration are, rather than being stored and created by an individual, distributed across embodied organisms and their environment. This paper postulates a stronger form of distributed narration than has been accommodated in the literature so far, which I call narrative deference. This describes the phenomena whereby a person is significantly dependent upon another person for the narration of some significant aspect of their own autobiographical self-narrative. I suggest that a person is more likely to narratively defer where they suffer a mnemonic impairment regarding some significant adverse life experience like trauma, illness or injury. Following a recent turn in the literature towards investigating the harmful aspects of distributed cognition as well as its many advantageous features, this paper explores how the benefits of autobiographical self-narrative deference within close personal relationships are complexly related to its harms.
Article
Full-text available
Background Intrusive memories of psychologically traumatic events bring distress both sub-clinically and clinically. This parallel-group, two-arm randomised controlled trial evaluated the effect of a brief behavioural intervention on reducing intrusive memories in frontline healthcare workers exposed to traumatic events during the COVID-19 pandemic. Methods Participants with at least two intrusive memories of work-related trauma in the week before recruitment were randomised 1:1 to an imagery-competing task intervention (n = 73) or attention-based control task (n = 71). The number of intrusive memories was assessed at baseline and 5 weeks after the guided session (primary endpoint). Results The intervention significantly reduced intrusive memory frequency compared with control [intervention Mdn = 1.0 (IQR = 0–3), control Mdn = 5.0 (IQR = 1–17); p < 0.0001, IRR = 0.30; 95% CI = 0.17–0.53] and led to fewer post-traumatic stress-related symptoms at 1, 3 and 6 month follow-ups (secondary endpoints). Participants and statisticians were blinded to allocation. Adverse events data were acquired throughout the trial, demonstrating safety. There was high adherence and low attrition. Conclusions This brief, single-symptom, repeatable digital intervention for subclinical-to-clinical samples after trauma allows scalability, taking a preventing-to-treating approach after trauma. Trial registration 2020–07-06, ClinicalTrials.gov identifier: NCT04460014.
Chapter
People with an intellectual disability (PWID) are at far greater risk of experiencing adverse and traumatic events arising from a multitude of factors. The current chapter provides a broad overview of the risk factors, both general and specific, to PWID that leads to various psychological sequelae. Special consideration is given to the importance of engaging in a broad and encompassing assessment that draws from a range of sources in being able to differentiate and accurately identify post-traumatic stress disorder (PTSD) in addition to common comorbid difficulties that may overshadow accurate assessment. Recent literature is also summarized that provides promising, albeit tentative, evidence for the effectiveness of modified treatments that target trauma symptoms.
Article
Objectives Trauma‐related conditions, such as post‐traumatic stress disorder, are associated with high rates of impairment and distress. Evidence‐based interventions for many trauma‐related conditions exert robust effects on their primary outcomes. However, logistical, financial, geographic and stigma‐related barriers to accessing these interventions exist. Methods Innovations that overcome barriers to access and engagement and increase the scalability of interventions for trauma‐related conditions are sorely needed. Results and Conclusions Here, we explore the following two potential avenues towards meeting this need: changes to the delivery model, including embedding interventions in settings which are already accessed by trauma‐exposed individuals (e.g. schools, social care systems) and harnessing advancements in technology to provide truly accessible trauma‐focussed interventions.
Article
Trauma is a risk factor for eating disorders (EDs). Enhanced understanding of the pathways from trauma to EDs could identify important treatment targets. Guided by theory, the present study sought to replicate previous findings identifying posttraumatic stress disorder (PTSD) symptoms and shape/weight overvaluation as important pathways between trauma and ED symptoms and extend this work by investigating the role of posttraumatic cognitions in these associations. The sample included 825 female and 565 male post-9/11 veterans who completed cross-sectional survey measures of trauma, posttraumatic cognitions, PTSD symptoms, shape/weight overvaluation, and ED symptoms. Gender-stratified structural equation models were used to examine direct and indirect pathways from trauma exposure to EDs via PTSD symptoms and shape/weight overvaluation (replication) and posttraumatic cognitions (extension). Results suggested that trauma exposure was indirectly associated with ED symptoms via shape/weight overvaluation and posttraumatic cognitions. There was no indirect association between trauma exposure and ED symptoms via PTSD symptoms. Overall, findings from this study highlight the potential role of posttraumatic cognitions in understanding the association between trauma and ED symptoms. However, future longitudinal research is needed to verify the directionality of these associations and investigate cognitions as a potentially targetable risk mechanism in co-occurring trauma and EDs.
Article
Co-occurring chronic pain and posttraumatic stress disorder (PTSD) is associated with poorer physical and mental functioning and well-being. Treatments often incorporate goal-setting around personally meaningful behaviors; however, it is unclear whether intentionally focusing on improving meaning and purpose in life (i.e., meaning-as-goal) may also serve as a helpful treatment target. The objective of the current study is to determine whether reported progress toward meaning-as-goal at 6 months is associated with pain severity and interference, physical and mental health functioning, and global meaning and purpose at 6- and 12-months. Data were collected as part of an evaluation effort focused on VA’s Whole Health System implementation efforts. VA electronic health records were linked to survey data across three time points (baseline, 6 months, and 12 months) from Veterans with both chronic pain and PTSD across 18 VA sites. A total of 1341 Veterans met inclusion criteria (mean age = 62, SD = 11.7). Regression analyses showed that progress toward meaning-as-goal was significantly associated with all 6-month variables, with standardized coefficients ranging from − 0.14 (pain severity and interference) to .37 (global meaning and purpose), in addition to all 12-month variables, with standardized coefficients ranging from − .13 (pain severity and interference) to .31 (global meaning and purpose). Efforts to intentionally promote meaning and purpose as part of evidence-based treatment for chronic pain and PTSD may lead to decreased pain and improved physical and mental health functioning and global meaning and purpose. With coefficients ranging from small to moderate effect sizes, more work is needed to better understand how best to maximize meaning-related goals.
Article
Full-text available
Purpose of Review In the last 15 years, there has been a burgeoning interest in moral injury, particularly among veterans and in high-risk occupational contexts. Estimates of exposure frequency to potentially morally injurious events (PMIEs) are high among veterans. Psychotherapies for posttraumatic stress disorder (PTSD) have been posited as sufficient for treating moral injury, which is tacitly conceptualized as a form of trauma. Several psychotherapies have also been developed to treat moral injury, or specific aspects of the purported syndrome (e.g., guilt). We describe and critically review individual and group psychotherapies that are putatively designed to address moral injury. Recent Findings There have been no randomized controlled trials using a primary endpoint of moral injury. Instead, investigators have chiefly argued that existing evidence-based therapies for PTSD are de facto appropriate for PMIE-exposed individuals. Consequently, there is insufficient evidence to suggest a best-practice approach. Summary There is still no consensus definition of moral injury, nor a widely used gold standard outcome measure, which has led to a body of research with significant validity issues. Clinical trials are needed that use clinically significant moral injury as an entry criterion, repeated assessments of moral injury symptoms, and the functional impact of those symptoms.
Article
Mental contamination refers to feelings of dirtiness and/or urges to wash that arise without direct contact with a contaminant. Cognitive models propose that this results from "serious, negative misappraisals of perceived violations". However, the specific violation misappraisals most relevant to mental contamination have yet to be established empirically, in part due to the lack of a comprehensive validated inventory of violation appraisals. Therefore, this study's aim was to develop and validate such a measure. Items for the new Violation Appraisal Measure (VAM) were developed from qualitative interviews, theoretical models, and previous empirical work. An Exploratory Factor Analysis was conducted in a sample of (n = 300) undergraduate participants, which revealed a four-factor structure: Responsibility/Self-Blame, Permanence, Mistrust, and Self-Worth. The VAM showed excellent internal consistency (α = 0.90), good convergent (r = .50 to .64) and adequate divergent (r = -.01 to .46) validity and was predictive of mental contamination symptoms over and above existing related appraisal measures, ΔF(1,289) = 29.35, p < .001, ΔR2 = 0.06. A Confirmatory Factor Analysis in a second sample of (n = 300) undergraduate students confirmed strong model fit for the four-factor structure of the VAM. The development of the VAM is an important contribution to the search for empirically based cognitive mechanisms in mental contamination and other violation-related sequelae.
Article
Full-text available
A cognitive theory of posttraumatic stress disorder (PTSD) is proposed that assumes traumas experienced after early childhood give rise to 2 sorts of memory, 1 verbally accessible and 1 automatically accessible through appropriate situational cues. These different types of memory are used to explain the complex phenomenology of PTSD, including the experiences of reliving the traumatic event and of emotionally processing the trauma. The theory considers 3 possible outcomes of the emotional processing of trauma, successful completion, chronic processing, and premature inhibition of processing We discuss the implications of the theory for research design, clinical practice, and resolving contradictions in the empirical data.
Article
Full-text available
Current thinking about Pavlovian conditioning differs substantially from that of 20 years ago. Yet the changes that have taken place remain poorly appreciated by psychologists generally. Traditional descriptions of conditioning as the acquired ability of one stimulus to evoke the original response to another because of their pairing are shown to be inadequate. They fail to characterize adequately the circumstances producing learning, the content of that learning, or the manner in which that learning influences performance. Instead, conditioning is now described as the learning of relations among events so as to allow the organism to represent its environment. Within this framework, the study of Pavlovian conditioning continues to be an intellectually active area, full of new discoveries and information relevant to other areas of psychology.
Article
Full-text available
Defines posttraumatic stress disorder (PSD), which has been used to circumscribe the varied symptoms reported by combatants, and briefly presents a conditioning model for the development of PSD. The model explains PSD as a combination of high-order conditioning and stimulus generalization. The benchmark symptoms for a diagnosis of PSD are (1) intrusive thoughts regarding the traumatic event, (2) vivid recollections of the traumatic event wherein the individual reports that he/she feels that the trauma is actually reoccurring, and (3) terrifying nightmares that contain specific details of the event. A previous study by the authors (unpublished) is reported in which several symptoms were assessed by evaluating Ss' performance on cognitive and behavioral tasks and by questionnaires selected for their relationship to specific symptoms to the disorder. Responses of PSD veterans on these tasks were compared to those of well-adjusted Vietnam combat veterans without PSD. Results show that performance on 5 of the 6 tasks was effective in distinguishing Vietnam veterans with PSD from those who were well adjusted: PSD Ss demonstrated increased physiological arousal; motoric agitation; intrusive, combat-related cognitions when exposed to cues resembling the original traumatic event; poor concentration; and poor performance on emotion identification. (26 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Full-text available
This article describes the development and validation of a new measure of trauma-related thoughts and beliefs, the Posttraumatic Cognitions Inventory (PTCI), whose items were derived from clinical observations and current theories of post-trauma psychopathology. The PTCI was administered to 601 volunteers, 392 of whom had experienced a traumatic event and 170 of whom had moderate to severe posttraumatic stress disorder (PTSD). Principal-components analysis yielded 3 factors: Negative Cognitions About Self, Negative Cognitions About the World, and Self-Blame. The 3 factors showed excellent internal consistency and good test-retest reliability; correlated moderately to strongly with measures of PTSD severity, depression, and general anxiety; and discriminated well between traumatized individuals with and without PTSD. The PTCI compared favorably with other measures of trauma-related cognitions, especially in its superior ability to discriminate between traumatized individuals with and without PTSD. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Full-text available
In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is defined as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual's responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.
Article
Full-text available
Intrusive recollections are very common immediately after traumatic events and are considered necessary aspects of emotional processing. However, if these intrusive recollections persist over a long time, they are linked to long-term psychiatric disorder, especially Posttraumatic Stress Disorder (PTSD). This paper discusses the need to investigate factors involved in the maintenance of intrusive traumatic recollections. It is suggested that the idiosyncratic meaning of the intrusive recollections predicts the distress caused by them, and the degree to which the individual engages in strategies to control the intrusions. These control strategies maintain the intrusive recollections by preventing a change in the meaning of the trauma and of the traumatic memories. It is further suggested that what is needed is a comprehensive assessment of the processes that prevent change in meaning, going beyond the assessment of avoidance. In particular, safety behaviours, dissociation and numbing, suppression of memories and thoughts about trauma, rumination, activation of other emotions such as anger and guilt and corresponding cognitions, and selective information processing (attentional and memory biases) may be involved in the maintenance of intrusive recollections. Preliminary data supporting these suggestions from studies of individuals involved in road traffic accidents and survivors of child sexual abuse are described.
Article
Full-text available
Cognitive processing therapy (CPT) was developed to treat the symptoms of posttraumatic stress disorder (PTSD) in rape victims. CPT is based on an information processing theory of PTSD and includes education, exposure, and cognitive components. Nineteen sexual assault survivors received CPT, which consists of 12 weekly sessions in a group format. They were assessed at pretreatment, posttreatment, and 3- and 6-month follow-up. CPT subjects were compared with a 20-subject comparison sample, drawn from the same pool who waited for group therapy for at least 12 weeks. CPT subjects improved significantly from pre- to posttreatment on both PTSD and depression measures and maintained their improvement for 6 months. The comparison sample did not change from the pre- to the posttreatment assessment sessions.
Article
Full-text available
This study examines the usefulness of the Trauma Symptom Checklist (TSC-40) in measuring the long-term sequelae of sexual abuse. In a national survey of 2,963 professional women, the TSC-40 was found to be reliable and to display predictive validity with regard to childhood sexual victimization. Women who reported a sexual abuse history scored significantly higher than did women with no history of abuse on each of the six subscales and on the overall TSC-40 score. Various aspects of childhood victimization were associated with the subscale scores, with the Sexual Abuse Trauma Index and Dissociation subscales being more sensitive to the specific components of the abuse.
Article
Full-text available
We present proposed changes to the dissociative disorders section of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders and review the concept of pathological and nonpathological dissociation, including empirical findings on the relations between trauma and dissociative phenomenology and between dissociation and hypnosis. The most important proposals include the creation of two new diagnostic entities, brief reactive dissociative disorder and transient dissociative disturbance, and the readoption of the criterion of amnesia for a multiple personality disorder diagnosis. We conclude that further work on dissociative processes will provide an important link between clinical and experimental approaches to human cognition, emotion, and personality.
Article
Full-text available
Explicit measures of human memory, such as recall or recognition, reflect conscious recollection of the past. Implicit tests of retention measure transfer (or priming) from past experience on tasks that do not require conscious recollection of recent experiences for their performance. The article reviews research on the relation between explicit and implicit memory. The evidence points to substantial differences between standard explicit and implicit tests, because many variables create dissociations between these tests. For example, although pictures are remembered better than words on explicit tests, words produce more priming than do pictures on several implicit tests. These dissociations may implicate different memory systems that subserve distinct memorial functions, but the present argument is that many dissociations can be understood by appealing to general principles that apply to both explicit and implicit tests. Phenomena studied under the rubric of implicit memory may have important implications in many other fields, including social cognition, problem solving, and cognitive development.
Article
Full-text available
In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is defined as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual’s responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.
Article
Full-text available
Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated life-time prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode. Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey. The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years. Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
Article
Full-text available
In a cross-validated mediational model, the authors examined characteristics of memories formed in response to rape and other intense unpleasant and pleasant experiences. Data were responses to a mailed survey of women medical center and university employees. Measurement models of memory and symptom factors and a structural model with pathways among cognitive appraisal, emotional valence, memory characteristics, and health outcomes were developed in Sample 1 (N = 1,307) and confirmed in Sample 2 (N = 2,142). Rape had substantial direct effects on 2 memory factors (Clarity and Affect) and indirect effects through the construal of victimization. Rape was associated with memories described as more emotionally intense but less clear and coherent and less often thought of or talked about. Most effects on physical symptoms were nonsignificant. Implications of findings for neurohormonal and multiple representation models of emotional memory and to cognitive avoidance are discussed.
Article
Review of book: Recovered Memories and False Memories by Martin A. Conway, New York: Oxford University Press, 1997, 301 pp. Reviewed by C. Brooks Brenneis.
Conference Paper
Anxiety disorders are characterised by distorted beliefs about the dangerousness of certain situations and/or internal stimuli. Why do such beliefs persist? Six processes (safety-seeking behaviours, attentional deployment, spontaneous imagery, emotional reasoning, memory processes and the nature of the threat representation) that could maintain anxiety-related negative beliefs are outlined and their empirical status is reviewed. Ways in which knowledge about maintenance processes has been used to develop focussed cognitive therapy programmes are described and evaluations of the effectiveness of such programmes are summarized. Finally, ways of identifying the effective ingredients in cognitive therapy programmes are discussed.
Article
Summary The main and the latest trends in the world and in Cuba regarding Posttraumatic Stress Disorder in female victims of rape, as well as the social factors that determine the general facts all over the nation and particularly in Pinar del Rio were analyzed using the historical method.
Article
A patient with selective bilateral damage to the amygdala did not acquire conditioned autonomic responses to visual or auditory stimuli but did acquire the declarative facts about which visual or auditory stimuli were paired with the unconditioned stimulus. By contrast, a patient with selective bilateral damage to the hippocampus failed to acquire the facts but did acquire the conditioning. Finally, a patient with bilateral damage to both amygdala and hippocampal formation acquired neither the conditioning nor the facts. These findings demonstrate a double dissociation of conditioning and declarative knowledge relative to the human amygdala and hippocampus.
Article
This chapter explores a question critical to the remainder of the chapters in the title: ‘what are memories?’ It discusses recovered memories and false memories, outlines the recovered memory debate and research into the area, before summarizing the content of the remaining chapters.
Article
Posttraumatic stress disorder (PTSD) is an illness of considerable prevalence, often characterized by high morbidity, treatment resistance, and a chronic course. The core symptoms of PTSD include persistent reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, and autonomic hyperarousal. We propose several neurobiologic mechanisms that may account for these primary symptoms of PTSD. Preclinical investigations of the effects of stress on learning and memory processes suggest that fear conditioning, behavioral sensitization, and a failure of extinction may be important in the persistence and reexperiencing of traumatic memories and stressor sensitivity. The pathophysiology of PTSD may involve dysfunction of several brain structures, particularly the amygdala, locus coeruleus, and hippocampus, as well as noradrenergic, dopamine, opiate, and corticotropinreleasing factor neurochemical systems. Acutely, severe psychological trauma results in the parallel activation of these systems, producing an array of adaptive behavioral and physiologic responses necessary for survival. In PTSD, however
Chapter
This chapter explores the nature of confession and inhibition. Conversely, not confiding significant experiences is associated with increased disease rates, ruminations, and other difficulties. This pattern of findings has helped in developing a useful theory of active inhibition that shares many of the assumptions of learning theory, psychodynamic models, and more recent cognitive perspectives. The chapter examines the nature of confession per se. The chapter focuses on the physiological and psychological effects of confronting or actively avoiding past traumatic experiences. Based on a number of laboratory and field studies, it is clear that requiring people to write or talk about traumas is associated with both immediate and long-term health benefits. The chapter presents a formal theory of active inhibition. The links among the theory and Freud, animal learning, and cognitive perspectives are discussed in the chapter. The chapter describes the reexamination of catharsis, the development and breakdown of the self, and the role of psychosomatics in social psychology.
Article
Background: Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated lifetime prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.Methods: Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.Results: The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.Conclusions: Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
Article
This paper reviews the evidence for the existence of a complex form of post-traumatic disorder in survivors of prolonged, repeated trauma. This syndrome is currently under consideration for inclusion in DSM-IV under the name of DESNOS (Disorders of Extreme Stress Not Otherwise Specified). The current diagnostic formulation of PTSD derives primarily from observations of survivors of relatively circumscribed traumatic events. This formulation fails to capture the protean sequelae of prolonged, repeated trauma. In contrast to a single traumatic event, prolonged, repeated trauma can occur only where the victim is in a state of captivity, under the control of the perpetrator. The psychological impact of subordination to coercive control has many common features, whether it occurs within the public sphere of politics or within the private sphere of sexual and domestic relations.
Article
provide a detailed review of the literature on the psychobiology of traumatic stress response syndromes and discuss the treatment implications of recent findings in this area / after a brief discussion of four primary features of trauma—incomprehensibility, disrupted attachment, traumatic bonding, and inescapability—the authors review three animal models for PTSD [posttraumatic stress disorder]: inescapable stress, forced isolation, and disruption of attachments in nonhuman primates / [reviews] the role of endogenous opioids in trauma responses and the psychobiology of reliving and reenactment (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
highlight recent progress made in studies of the neurobiology of dissociative states, memory dysfunction, and hyperarousal in posttraumatic stress disorder (PTSD) patients / review and begin to integrate recent studies of PTSD patients, other patient populations, healthy Ss, and preclinical research / highlight the potential prognostic and therapeutic significance of recent research findings [on] the neurobiology of dissociative states and memory disturbance in PTSD (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Integrates findings from the fields of cognitive science, child development, and trauma to address basic questions about posttraumatic stress disorder (PTSD). Mechanisms of divided attention and emotional flooding during traumatic experiences may explain classic memory (ME) findings in PTSD: psychogenic amnesia in the setting of hyperarousal, startle response, intrusive images, and avoidance behaviors. Cognitive research shows that blocked focal attention leads to impaired explicit processing but intact implicit recall. The hippocampal formation is crucial for explicit ME processing, involving a subsequent consolidation process that is postulated to make MEs permanent in the cortex. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
From the perspective of memory researchers, there are 3 broad areas in which questions need to be posed about the state of evidence relevant to the recovered memories debate. The 1st set of questions concerns the issue of 'forgetting.' The 2nd set of questions concerns the issue of 'distortion.' The 3rd set of questions concerns the relation between recovered memories of actual abuse and illusory memories of abuse. In this chapter, we examine evidence that pertains to each set of questions. For each set, we summarize briefly the state of knowledge regarding memories of childhood sexual abuse. We also broaden the frame of analysis to consider relevant evidence from other areas of research, including clinical observations of traumatic memory as well as current cognitive psychology and cognitive neuroscience. Our goals are twofold. The first is to provide our own assessment of the state of the evidence in the recovered memories debate. Here, we emphasize that answers to the various questions we have posed need not all point toward the same side of the debate. For instance, it is perfectly possible to conclude, as we do, that illusory memories of abuse exist yet at the same time concede that some traumatic experiences can be forgotten and later recovered. The 2nd goal is to seek guidance and direction for future research from current work on remembering and forgetting. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Cognitive models have linked individual differences in the appraisal of traumatic events and their sequelae to the persistence of post-traumatic stress disorder (PTSD). A pilot study investigated this proposal with victims of assault. Eleven assault victims suffering from persistent PTSD and 9 victims who had recovered from PTSD were interviewed retrospectively and compared on potentially relevant cognitive factors. Groups were comparable in terms of characteristics of the assault, gender, age, and initial PTSD severity. Participants with persistent PTSD were less likely than those who had recovered to have engaged in mental planning during the assault and more likely to have experienced mental defeat, and to indicate negative appraisals of their actions during the assault, of others' reactions after the assault, and of their initial PTSD symptoms. They were also more likely to indicate global negative beliefs concerning their perception of themselves, their world or their future. These cognitive factors may maintain PTSD symptoms either directly or by motivating the individual to engage in behaviour that prevents change.
Article
This study examined feelings of anger among female victims of crime and the relation of anger to the development of post-traumatic stress disorder (PTSD). One hundred and sixteen women who had been victims of sexual or nonsexual criminal assaults were compared to a matched comparison group of 50 nonvictimized women on measures of anger and anger expression. Results indicate that victims were angrier than nonvictims. The level of anger was related to various aspects of the assault, such as the use of a weapon and the victim's response to the attack. In addition, the results indicate that elevated anger is positively related to the development of PTSD. Results are discussed in relation to a cognitive/behavioral conceptualization of PTSD.
Article
In this study we examined the relationship between posttrauma pathology and the level of articulation (complexity) in rape narratives recounted by victims shortly after the assault. Degree of articulation was operationalized as the reading level of the narratives as determined by a computer program. Shortly after the trauma, reading level was correlated with severity of anxiety but not with posttraumatic stress disorder (PTSD) symptoms. Degree of the narrative articulation shortly after the trauma, however, was related to severity of later PTSD. These results are consistent with the hypothesis that the less developed trauma narratives hinder recovery from trauma.
Article
Not all patients with posttraumatic stress disorder benefit from exposure treatment. The present paper describes two cognitive dimensions that are related to inferior response to exposure in rape victims. First, individuals whose memories during reliving of the trauma reflected mental defeat or the absence of mental planning showed little improvement. Second, inferior outcome was correlated with an overall feeling of alienation or permanent change following the trauma. These results are based on blind ratings of transcripts of exposure treatment sessions from 10 women with good outcome and 10 women with inferior outcome. Patients in the two groups were matched for initial symptom severity and were comparable in many aspects of the assault. Patients who experienced mental defeat, alienation, or permanent change may require cognitive restructuring in addition to exposure.
Article
This paper presents a coding system developed to explore changes in narratives of rape during therapy for posttraumatic stress disorder (PTSD) involving repeated reliving and recounting of the trauma. Relationships between narrative categories hypothesized to be affected by the treatment and treatment outcome were also examined. As hypothesized, narrative length increased from pre- to post-treatment, percentage of actions and dialogue decreased and percentage of thoughts and feelings increased, particularly thoughts reflecting attempts to organize the trauma memory. Also as expected, increase in organized thoughts was correlated negatively with depression. While indices of fragmentation did not significantly decrease during therapy, the hypothesized correlation between decrease in fragmentation and reduction in trauma-related symptoms was detected.
Article
Post-traumatic stress disorder (PTSD) and related psychopathology were examined in 95 female rape victims beginning soon after the assault (mean=12.64 days). Subjects were assessed weekly for 12 weeks. Ninety-four percent of women met symptomatic criteria for PTSD at Assessment 1, decreasing to 65% at Assessment 4 (mean=35 days postassault), and 47% at Assessment 12 (mean=94 days postassault). PTSD and related psychopathology decreased sharply between Assessments 1 and 4 for all women. Women whose PTSD persisted throughout the 3-month study did not show improvement after the fourth assessment; women who did not meet criteria for PTSD 3 months postassault showed steady improvement over time. This pattern was evidenced even after initial PTSD severity was statistically controlled. Moreover, PTSD status at 3 months postassault could be predicted with a high degree of accuracy by two brief self-report measures administered at the first assessment. The implications of the present findings and directions for future research are discussed.