Content uploaded by Sheila A M Rauch
Author content
All content in this area was uploaded by Sheila A M Rauch on Mar 13, 2015
Content may be subject to copyright.
A preview of the PDF is not available
Emotional Processing Theory (EPT) and exposure therapy for PTSD
Abstract
Emotional processing theory developed by E. B. Foa and M. J. Kozak (1986) has informed the conceptualization of anxiety disorders and the development of effective treatments for these disorders, including posttraumatic stress disorder (PTSD). This article presents a summary and update of emotional processing theory as it applies to the treatment of PTSD, data in support of this theory, and clinical examples of how the theory can be used to assist in the treatment of clients with PTSD. Common difficulties confronted during exposure therapy for PTSD, including underengagement and overengagement, are discussed in the context of emotional processing theory and suggestions for how to manage these difficulties are presented.
... First, emotional processing theory has been foundational in exposure therapy [41], emphasizing fear activation and habituation within (i.e., within-session habituation) and across (i.e., between-session habituation) sessions. Effective treatment, according to this theory, requires modification of the pathological features and incorporation of new elements in a fear structure in memory [42,86]. Second, inhibitory learning theory has more recently gained attention [29,30]. ...
... In light of this, during this study we will explore the assumption that similar mechanisms are at play in VRE and IVE. Traditionally, fear habituation was considered the 'active ingredient' of exposure [42,86]. However, in recent years, the consensus has shifted towards viewing a mismatch between expected and actual outcomes as the most significant driver of symptom reduction and as such exposure is often conducted in ways where this mismatch can be maximized [29,30,81]. ...
While virtual reality exposure (VRE) has shown effectiveness in treating social anxiety in adults, research on its efficacy for adolescents remains limited. Given that adolescence is a critical period for early intervention, this study aims to address this gap by evaluating the efficacy and acceptability of VRE compared to in vivo exposure (IVE) in a non-referred sample of socially anxious adolescents. Additionally, we seek to identify mechanisms of change—such as expectancy violation, habituation, and self-efficacy—as well as predictors of treatment response, including clinical, personality, and VR-related factors. Using a randomized controlled trial (RCT), 120 adolescents (ages 12–16) with subclinical to moderate social anxiety will be assigned to one of three conditions: VRE, IVE, or a waitlist control (WL). Participants in the active conditions will undergo a seven-session exposure-based intervention (either in VR or in vivo). Primary (SPAI-18, LSAS-avoidance) and secondary (SPWSS) measures of social anxiety, along with general well-being indicators (e.g., resilience, depression, psychosocial functioning), will be assessed at baseline, post-treatment, and 3- and 6-month follow-ups. A series of linear mixed model (LMM) analyses will be used to examine and compare the effects of the interventions. We hypothesize that both VRE and IVE will significantly reduce social anxiety symptoms compared to WL at post-assessment, with comparable long-term efficacy between the two exposure methods. Additionally, thematic analyses will be conducted to explore participants’ experiences and acceptance of VRE and IVE through qualitative interviews. The findings of this study aim to advance digital mental health research by evaluating the potential of VRE as an early intervention and identifying mechanisms and predictors to inform personalized treatments for socially anxious youth.
Trial registration
Clinicaltrials.gov: NCT06379633, registered on April, 23, 2024.
... People who suffer from posttraumatic stress disorder (PTSD) tend to hold negative beliefs about themselves, others, and the world. In different theoretical models of PTSD, negative trauma-related cognitions about the trauma and its sequala have been suggested to be central in PTSD symptom development and maintenance (Ehlers & Clark, 2000;Rauch & Foa, 2006;Resick & Schnicke, 1992). Indeed, many empirical studies have underscored the centrality of negative cognitions and its relationship with the onset, maintenance, and recovery from PTSD (Brown et al., 2019;Gómez de La Cuesta et al., 2019). ...
... For instance, someone may hold the negative belief that the world is dangerous and may therefore wrongfully expect to be attacked when going out. Negative expectancies are theorized to be overestimated in both likelihood and cost by individuals with PTSD (Ehlers & Clark, 2000;Rauch & Foa, 2006). Moreover, experimental psychopathology studies have shown that negative threat expectancies are related to the development and severity of PTSD symptoms (Engelhard et al., 2009;Herzog et al., 2022;Kimble et al., 2018). ...
Purpose
Dysfunctional threat appraisal plays a key role in both the development and treatment of PTSD. It is unclear how these appraisals can best be measured. This study aimed to explore the specific negative outcome predictions held by patients with PTSD and to develop and validate the Threat Appraisal in PTSD Scale (TAPS).
Methods
We used data from a non-clinical (N = 309) and clinical sample (N = 125) to assess the psychometric properties of the TAPS.
Results
The TAPS had excellent internal consistency and test-retest reliability, and convergent and discriminative validity were adequate. The TAPS showed to be sensitive to change following treatment. The TAPS demonstrated incremental validity beyond general cognitions in predicting PTSD symptoms in the combined sample, but not in the patient sample. An exploratory factor analysis suggested three factors: ‘losing control’, ‘externalizing reactions’, and ‘physical reactions’, and patients seemed most concerned about outcomes related to ‘losing control’.
Conclusions
These findings imply that the TAPS could be clinically beneficial, enabling patients and therapists to recognize dysfunctional expectancies and tailor therapeutic interventions accordingly.
... This notion is further supported by a close affect-specific link between heart rate and neural activity in integral parts of the limbic system (Kuniecki, Barry, & Kaiser, 2003;Yang et al., 2007), a network crucial for memory consolidation (Catani, Dell'acqua, & Thiebaut de Schotten, 2013) and known to be altered in individuals with PTSD (Shin, Rauch, & Pitman, 2006). Generally speaking, when dealing with traumatic experiences, emotional engagement up to a certain degree as opposed to detachment (i.e., dissociation) has been shown to be beneficial in preventing or reducing PTSD symptoms, presumably by supporting adaptive (nocturnal) emotional memory processing (Möller, Söndergaard, & Helström, 2017;Rauch & Foa, 2006). However, it remains to be determined whether there are certain levels of arousal at different time points around a traumatic event that are beneficial for or detrimental to adaptive memory encoding and subsequent (nocturnal) consolidation (see e.g., Chou et al. (2014) for an attempt to decipher distinct effects of increased arousal at different time points around an analog traumatic event). ...
Recent evidence shows a strong correlative link between sleep disturbances and intrusive memories after traumatic events, presumably due to insufficient (nocturnal) memory integration. However, the underlying mechanisms of this link and the role of specific neural activities during sleep are poorly understood so far. Here, we investigated how the intra-individual affective response to an experimental trauma predicts changes in oscillatory activity during subsequent sleep and how these changes predict the processing of the experimental trauma. In a randomized within-subject comparison, twenty-two female, healthy participants (23.14 ± 2.46 years) watched a well-validated film clip including “traumatic” contents and a neutral film clip before bedtime on two separate nights. Heart rate was recorded during the film clips and nocturnal brain activity was recorded using 64-channel high-density EEG during subsequent nights. Intrusive memories were assessed via a seven-days diary and negative affect was assessed using laboratory trauma film reminders one week after the trauma film. An increased intra-individual heart rate during the trauma film predicted higher intra-individual sleep spindle amplitude the following night. Increased theta activity (4.25 - 8 Hz) during rapid eye movement (REM) sleep after the trauma film predicted fewer trauma film related intrusive memories and negative affect. Likewise, an increase in sleep spindles after the trauma film predicted fewer trauma film related intrusive memories. Our findings suggest that an experience-dependent up-regulation of these nocturnal oscillatory activity patterns, which are known to be involved in adaptive memory consolidation processes, serves as a protective factor against trauma-related intrusive memory development. Particularly, increased theta activity during REM sleep and sleep spindle activity seem to be of importance here.
... In our research and clinical experience, psychophysiological measures can be beneficial for enhancing emotional engagement in therapist-guided exposures, while also providing a means of biofeedback to compellingly index treatment response, thereby spurring therapeutic change. Additionally, while emotional engagement has been posited as requisite for therapeutic change to occur in exposure-based interventions (Foa & Kozak, 1986;Rauch & Foa, 2006), the correspondence between subjective and objectively-measured physiological engagement is low and confounded with prognosis. For example, the most symptomatic and impaired individuals with PTSD report the greatest subjective distress and engagement with trauma-related imagery, but do not show corresponding increases in physiological arousal (McTeague et al., 2010;McTeague & Lang, 2012) Accordingly, physiological measures of engagement in exposure may also serve as a clinically-meaningful prognostic indicator. ...
Many psychotherapy interventions have a large evidence base and can help a substantial number of people with symptoms of mental health conditions. However, we still have little understanding of why treatments work. Early advances in psychotherapy, such as the development of exposure therapy, built on theoretical and experimental evidence from Pavlovian and instrumental conditioning. More generally, all psychotherapy achieves change through learning. The past 25 years have seen substantial developments in computational models of learning, with increased computational precision and a focus on multiple learning mechanisms and their interaction. Now might be a good time to formalize psychotherapy interventions as computational models of learning to improve our understanding of mechanisms of change in psychotherapy. To advance research and help bring together a new joint field of theory-driven computational psychotherapy, we first review literature on cognitive behavioral therapy (exposure therapy and cognitive restructuring) and introduce computational models of reinforcement learning and representation learning. We then suggest a mapping of these learning algorithms on change processes presumably underlying the effects of exposure therapy and cognitive restructuring. Finally, we outline how the understanding of interventions through the lens of learning algorithms can inform intervention research.
Background: Posttraumatic stress disorder (PTSD) and chronic pain are devastating conditions that often co-occur. Current understanding of comorbid PTSD and chronic pain is limited, and treatment options are undereffective.
Objective: This paper presents a theoretical basis for conceptualising chronic pain symptoms within Emotional Processing Theory (EPT), the foundation for Prolonged Exposure (PE), an effective treatment for PTSD. EPT conceptualises the development and treatment of PTSD using a trauma structure that strongly overlaps with pain’s neurobiology.
Method: This paper proposes a model of shared aetiology and treatment of comorbid PTSD and chronic pain, emphasising these shared neurobiological underpinnings. Discussion details how the comorbidity is maintained through parallel avoidance processes focused on: (1) trauma memories and reminders in PTSD preventing reduction of negative affect (extinction) and inhibitory learning, and (2) physical pain in chronic pain fuelling increased pain and reduced function.
Results: A conceptualisation is presented on how PTSD and chronic pain symptomology can be addressed within the EPT framework, increasing the confidence of providers and patients while addressing an important gap in the literature. Finally, recommendations for providers using PE with patients with PTSD and pain are provided including a case example and treatment plan based on real patients.
Conclusions: This model provides a clinically useful understanding of the underlying neurobiology for the co-occurrence of PTSD and chronic pain and offers direction for future research.
Adolescents in domestic work in Nigeria are at heightened risk of mental health problems resulting from sexual abuse, exploitation, condition of work and neglect. One of such mental health problems is Posttraumatic Stress Disorder (PTSD). This paper explored posttraumatic stress disorder among adolescents in domestic work in the Nigerian context. According to APA (2013) PTSD has five cluster symptoms such as exposure to traumatic events (directly or vicariously), intrusive symptoms, Persistent avoidance of stimuli associated with the traumatic event(s), Negative alteration in cognitions and mood associated with the traumatic event(s) and Marked alterations in arousal and reactivity associated with the traumatic event(s). Ignoring the challenges faced by adolescents in domestic work can lead to disruptions in education, risk for child abuse, mental health issues, poor knowledge of sexual and reproductive health (SRH) services as well as proper transition to adulthood. Psychological interventions such as Trauma-focused cognitive behavioural therapy, Eye movement Desensitization and Reprocessing therapy and Play therapy were identified and should be utilized for adolescents with PTSD. This study recommended the need to create awareness among the general public on risks adolescents in domestic work face, need for better parenting education for parents who sent their children for domestic work and need for the implementation of legal instruments that protect children and promote their well-being.
Emergency and critical care personnel face a heightened risk of occupational trauma exposure. Practitioners lack clear guidance on how to support individuals who are off work with work-related posttraumatic stress disorder (PTSD), particularly those receiving treatment in the context of a claim with a workers’ compensation board. While trauma-focused psychotherapies are recommended as first-line interventions for PTSD, there is an ongoing discourse about how to address the increased functional impairments of individuals who are off work, and how to best support individuals struggling with in-vivo exposures and return to work. This article utilizes case studies involving an intensive care unit nurse and an emergency dispatcher, to demonstrate how occupational therapists can collaborate with psychotherapists to address functional impairment following workplace trauma to support clients in their mental health recovery and return to the workplace. Beyond the traditional focus on non-trauma-related treatment domains, occupational therapists are uniquely positioned to address trauma-focused aspects of therapy. Strengthening the partnership between occupational therapists and psychotherapists has the potential to improve treatment outcomes, promote work reintegration, and provide comprehensive and holistic care that addresses the clients’ full spectrum of needs.
This study examined 2 process variables, emotional engagement and habituation, and outcome of exposure therapy for posttraumatic stress disorder. Thirty-seven female assault victims received treatment that involved repeated imaginal reliving of their trauma, and rated their distress at 10-min intervals. The average distress levels during each of 6 exposure sessions were submitted to a cluster analysis. Three distinct groups of clients with different patterns of distress were found: high initial engagement and gradual habituation between sessions, high initial engagement without habituation, and moderate initial engagement without habituation. Clients with the 1st distress pattern improved more in treatment than the other clients. The results are discussed within the framework of emotional processing theory, emphasizing the crucial role of emotional engagement and habituation in exposure therapy.
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.
In Exp. I with 29 female undergraduates, an apparatus designed to administer systematic desensitization automatically was as effective as a live therapist in reducing phobic behavior, suggesting that effective desensitization is not dependent on a concurrent interpersonal interaction. An extensive psychophysiological analysis of the desensitization process showed that Ss' fear signals are associated with an increment in autonomic arousal, and that repreated presentation of fear items is accompanied by reduction in autonomic activity. Heart rate levels, responses, and degree of habituation to fear stimuli appeared related to success of desensitization. In Exp. II with 5 male and 15 female Ss, the anxiety hierarchies developed for desensitization yielded autonomic gradients, when the items were presented as visualized scenes, that varied with fear content and reported clarity of visualization. Results support the view that desensitization modifies autonomic, as well as gross motor and verbal responses, through learning.
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.
A theory of emotional imagery is described which conceives the image in the brain to be a conceptual network, controlling specific somatovisceral patterns, and constituting a prototype for overt behavioral expression. Evidence for the hypothesis that differentiated efferent activity is associated with type and content of imaginal activity is considered. Recent work in cognitive psychology is described, which treats both the generation of sensory imagery and text comprehension and storage as examples of the processing of propositional information. A similar propositional analysis is applied to emotional imagery as it is employed in the therapeutic context. Experiments prompted by this view show that the conceptual structure of the image and its associated efferent outflow can be modified directly through instructions and through shaping of reports of image experience. The implications of the theory for psychopathology are considered, as well as its relevance to therapeutic behavior change.
Prolonged Exposure therapy (PE; Foa & Rothbaum, 1998) has strong empirical support for its efficacy in reducing trauma-related psychopathology in individuals with chronic PTSD (Rothbaum, Meadows, Resick, & Foy, 2000). In the process of providing PE to many clients and in training therapists in a variety of settings in its use, we at the Center for the Treatment and Study of Anxiety have amassed extensive experience with this therapy. This article extends the treatment guidelines provided in the PE treatment manual by sharing the knowledge and wisdom that years of experience have brought us. We emphasize the importance of forging a strong therapeutic alliance and providing a thorough rationale for treatment, discuss ways to implement in-vivo and imaginal exposure so as to promote effective emotional engagement with traumatic memories, and conclude with some recommendations for how therapists who conduct PE for PTSD can take care of themselves while delivering a therapy that is very rewarding and, at times, emotionally challenging.
The present study examined the effects of total exposure duration and interrupted versus continuous exposure on flooding for public speaking anxiety. Total exposure durations of 100, 150, and 200 min were compared with either 50 min of continuous scene presentation or with two 25-min presentations separated by a 10-min interval. Dependent measures included behavioral, self-report and physiological indices. Continuous exposure was clearly superior to interrupted exposure. Explanation for this finding may be found in the habituation data on self-reported anxiety during treatment sessions. Continuous exposure led to a curvilinear pattern of self-reported anxiety, with anxiety first increasing then decreasing. Interrupted flooding led to increasing linear patterns of anxiety during each session. Total exposure duration of 100 min (two sessions) appeared sufficient for this population and disorder.
An analysis of fear imagery in behavior therapy is developed from the combined perspectives of information processing theory and psychophysiology. Recent thought on imagery processing and storage is considered, and it is argued that affective images are best viewed as propositional structures rather than as iconic or holistic sensory representations. A method is presented for manipulating the image through instructions, and an image taxonomy of stimulus and response components is described. The usefulness of bioelectric measurement is emphasized throughout, and this is illustrated in an experiment derived from the “constructive” concept of imagery. The implications of this approach are then developed for behavior modification research: Desensitization and flooding are analyzed, comparisons are made among media, imaginal, and in vivo fear treatments, and the significance of image analysis is elucidated for both overt and covert modeling. In conclusion, a general model for fear processing is described and directions for future research are outlined.