Cognitive Theories and Models

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All cognitive theories of Posttraumatic Stress Disorder have the following features or components in common, according to Dalgleish (1999):

■ Individuals have pretrauma beliefs and models of the world, self, and others that come into play when a trauma occurs.

Traumatic stressors provide salient and typically incompatible information relative to these beliefs and models.

■ Such information cannot be easily ignored nor integrated or assimilated into these existing belief structures and models.

■ The process of attempting to integrate this difficult and problematic information leads to what is observed as the PTSD phenomena (i.e., symptoms and signs of the disorder).

■ Successful resolution results in integration. Unsuccessful resolution occurs when the traumatic information cannot be brought into line with the pre-trauma cognitive environment.

Cognitive theories or models are also known as information processing models. Litz and Hearst give a good description of the relevant concepts from an information processing perspective, which include:

hypothetical [mental] constructs, derived from experimental cognitive psychology, that address how individuals perceive, selectively attend to, and retrieve personally relevant information from memory. Information processing . . . addresses how life experiences are organized in memory in a manner that facilitates the utilization of past experience. Past experience is organized in memory in functional units called networks or schemas . . . Information processing theories of PTSD posit that traumatic life experiences influence how new information relevant to the trauma is processed. (p. 4)

Key words or concepts in this chapter will be memory, networks, and schemas. Each of these are essential constructs in the cognitive conceptualization of PTSD.

Mardi Horowitz's Stress Response Syndrome

The psychiatrist Mardi Horowitz has been an integral part of the PTSD field for decades. His theoretical work was a critical component in the development of the DSM-III version of PTSD. Horowitiz's model of PTSD has its theoretical roots in Freudian and psychodynamic theory. However, his is essentially a cognitive-processing model in which individuals are seen as active processors of incoming information from their environment, working to integrate, assimilate, or accommodate, à la Jean Piaget, the new or novel information into existing psychological structures, schemas, or models of the world.

Initially, we start with a traumatic stressor. From here an individual engages in the cognitive processing of the incoming trauma-related information. At the center of this process is a basic human tendency called the completion tendency, which Horowitz defines as the need to match new information with inner models based on older information and the revision of both until they agree (Horowitz, 1986). Dalgleish (1999) states that this process helps the mind make effective decisions and choose courses of action by staying in touch with reality. In other words, the partaking in processing is preferable over simply shutting down or totally shutting out the incoming traumatic stimuli, as the latter would result in ineffectual responding.

Horowitz (1986) states that traumatic stress requires a person to process incoming information as threatening. He cites the work of Lazarus (1966; see Chapter 2 for more on Lazarus), which emphasizes the role of cognitive appraisal in determining idiosyncratic stress responses. Different people interpret different stimuli differently. Once a stressor is determined to be traumatic, we engage in the integration process, alternating between periods of intrusion and engagement of denial-based defensive mechanisms. Intrusion refers to the awareness of the traumatic stimuli, and denial refers to the lack of conscious acknowledgment. This process allows for the natural titration of traumatic stress, and ideally ends in integration and resolution. Intrusion periods involve symptoms of reexperiencing and hyperarousal. Intrusion then gives way to denial, numbing, and avoidance symptoms.

Horowitz proposes that processing occurs in a multistage process that we engage in and pass through on our way to resolution or integration. They are as follows:

1. A crying out or stunned reaction occurs.

2. An information overload occurs. Thoughts, memories, and images of the trauma cannot be integrated, and there is a failure to integrate (Dalgleish, 1999).

3. An engagement ofdefense mechanisms occurs. Despite defense mechanisms, the completion tendency maintains the traumatic information in active memory, leading to intrusive symptoms such as flashbacks, dreams, or intrusive thoughts. There is an oscillation between defense and completion tendency, accompanied by gradual integration. Failures of integration lead to partial processing of trauma information and their remaining in active memory, thus leading to symptom production.

As intrusion is processed and is properly integrated, normal adaptation occurs. Appropriate and effective defensive functioning facilitates this process. If the defensive functions fail to facilitate this process, traumatic information is only partially processed and is maintained in active memory, readily accessible, easily activated, and overt symptoms emerge.

Janoff-Bulman's Cognitive Appraisal Model

The core of this model rests on the idea that humans have basic ideas or mental models of the world and themselves in that world that allow them to plan, make decisions, react, and generally function. They can be seen as primary programs or operating systems that guide our thoughts, emotions, and actions. In the cognitive appraisal model of Janoff-Bulman (1992), PTSD is the consequence of the shattering of basic assumptions or models about ourselves or the self and the world.

There are three critical core assumptions that are affected with PTSD. The first assumption is that we are personally invulnerable or safe. This is characterized by statements or beliefs such as, "It won't happen to me," or "That only happens to people who . . .," and so on. The second assumption involves the perception that the world is meaningful and comprehensible. In other words, nothing happens without a reason and the world is understandable and makes sense. Finally, the third assumption is that the self is viewed in a positive way. That is, we generally see ourselves in a positive light. Our self-concept is not generally negative. Dalgleish (2004) proposes that these beliefs provide structure and meaning to our experience, and when they are challenged or shattered, the world is experienced as chaotic, confusing, intrusive, and to be avoided or escaped from. We become overstimulated and hyperaroused. I would add that the very human need to live in a predictable world is powerfully challenged by traumatic stress. Car accidents happen despite our best preparation against them. Unthinkable atrocities are committed all over the world, everyday. "Strong" people break down when under stress, surprising themselves and those around them.

Edna Foa's Fear Network

Edna Foa and her colleagues (1989) proposed a model that is based on the activation of particular components of our memory, which subsequently lead to symptom expression. The groundwork for this work was laid by researcher Peter Lang. Lang (1985a, 1985b, 1987) proposed that stimuli that are fear-relevant are arranged and stored in highly organized, semantic, fear networks in memory. Information about cues that elicit fear; information about cognitive, motor, and psychophysiological responses; and information about the meaning of cues and responses are all part of these networks. Fear stimuli activate these networks and all its related components. Lang (1985a, 1985b, 1987) proposed that Anxiety Disorders as a class are characterized by stimuli-sensitive and stable fear networks that can be triggered more easily in patients with Anxiety Disorders than in patients without Anxiety Disorders. Quite simply, Anxiety Disorder patients react to a broader range of stimuli.

In line with Lang, Foa and her colleagues (1989) proposed that in PTSD, the trauma-related information stored in a fear network could be activated and brought into conscious awareness by cues or cue stimuli in the current biopsy-chosocial environment. When this happens, we engage in defense attempts to avoid or suppress this conscious recollection. Successful resolution of this cycle comes from integration of the information into more stable, less volatile memory structures. Foa and colleagues (1989) identifies some mediating variables for determining successful or unsuccessful integration. The more unpredictable and uncontrollable a stressor is perceived to be, the more resistant to integration it will be. Severe trauma that alters memory and attention functioning in a way that disorganizes and fragments the fear network makes trauma information resistant to integration. Peritraumatic dissociation is an example of a process that can interfere with the organization of trauma-related information and increase the fragmentation of memory.

Cognitive Action Theory

Chemtob et al. (1988) have developed a model similar to Foa et al.'s (1989) fear network model. It is significantly different, however, in that the fear network is considered permanently activated, resulting in the PTSD sufferer essentially being in a perpetual state of trauma and survival mode. This survival mode is characterized as the typical functional response mode to traumatic stress. In Foa et al.'s (1989) model, the fear network required cueing. This model has no such requirement but still allows for it. The fear network is simply on all the time. This perpetual activation leads to observed symptoms of hyperarousal and intrusive-ness. There is a constant state of alert and interpretation of a stimulus as such. Even neutral stimuli can be interpreted as threatening.

In addition to the ongoing or perpetual activation process, there are parallel processes that further account for symptoms. With each episode of arousal, there is a decrease in the interval between each episode. Episodes are then experienced more often. It's akin to the decreasing radius of a tornado as one gets closer to its core. Along with this change in interval and frequency of occurrence, the magnitude of activation increases with each episode. In essence, the fear network feeds back onto itself, becoming more common and more intense. Thus, an initially cued activation becomes virtually independent of cues, and as the episodes take on virtual lives of their own, the result is perpetual activation.

Cognitive Processing Model

Creamer, Burgess, and Pattison's (1992) cognitive processing model combines the work of Horowitz (1986), Foa et al. (1989), and Chemtob et al. (1988) into a model that explains recovery and the possible therapeutic mechanism in therapy. The activation of fear networks is seen as a necessary component for recovery from trauma. This process is called network resolution processing. There is an initial period of intrusion because the fear network is activated or stimulated. This initial intrusiveness, however, is followed by the use of defense mechanisms and avoidance. The higher the level of intrusion at the end of the acute stressor period, the better the outcome for the individual and the better the chances for healthy adaptation and recovery. The less denial, avoidance, and dissociation up front, the quicker the recovery process. It's as if the mind has less to dig up and process on a conscious level.

Dual Representation Theory

Brewin, Dalgleish, and Joseph (1996) proposed their dual representation theory in line with others' work and with emphasis on memory and the storage of trauma-related information. They proposed that trauma information is stored on two levels of memory, one on a conscious memory level called verbally accessible memories (VAMs) and one that is susceptible to cues but is unconscious called sit-uationally accessible memories (SAMs). Verbally accessible memories can be deliberately accessed and processed, perhaps, for example, in response to a therapist asking a client to talk about what they remember from a trauma. On the other hand, SAMs cannot be deliberately accessed but can be activated by cues.

Each level of storage gives rise to different PTSD symptom phenomenon. Verbally accessible memories give rise to intrusive memories, emotions, and selective recall of particular aspects of an event or events. Situationally accessible memories give rise to flashbacks, dreams, and situational arousal. Posttraumatic Stress Disorder sufferers need to consciously integrate VAM information into preexisting beliefs and models of the world and "restoring a sense of safety and control, by making appropriate adjustments to expectations about the self and world" (p. 8). From this will follow the integration of SAM information as new but ultimately nonthreatening information and the eventual creation of new SAMs.

Chronic PTSD symptoms occur when the discrepancy between the trauma and prior assumptions is very large, resulting in chronic emotional processing. The system keeps working to process and integrate the VAM and SAM information, but the discrepancy is too large. Processing and integration can also be stalled by avoidance of stimuli, resulting in an insufficient level of activation necessary for integration to properly occur.

Ehlers and Clark's Model of the Maintenance of PTSD

Posttraumatic Stress Disorder is a disorder in which a past threat is experienced as a current threat. How an event is interpreted and how trauma memory is represented are key factors. Ehlers and Clark (2000) propose that the integration of traumatic memory with existing memory is critical for stabilization and health. Trauma memories are strong and cohesive, leading to a broad range of trauma stimuli and overgeneralization and in essence, many stimuli are infected, if you will, by the trauma (Ehlers and Clark, 2000). Coping behavior based on threat stands in the way of cognitive resolution and serves to perpetuate symptoms. Sufferers never test their belief that there is a threat in the current moment if they are constantly avoiding or enacting their alert status (Ehlers & Clark, 2000).

Dalgleish and Power's SPAARS Approach

The schematic, propositional, analogue, and associative representational systems (SPAARS) model (Dalgleish, 1999; Power & Dalgleish, 1997, 1999) is a model of emotion used as a comprehensive attempt to integrate the emotional or, more specifically, fear processing aspects of PTSD with the memory-based approaches discussed so far. The schematic, propositional, analogue, and associative representational model represents the system and architecture involved in the storage of information, the interaction and relationship of this information, and how this information is processed. Schematic information is higher order—linguistic and conceptual representations of the self, the world, and goals. Propositional information consists of memory bits, such as beliefs, objects in the world, and concepts. Associative information consists of the relationships between both schematic and prepositional information. Analogue representation consists of the more primitive or basic perceptual units of a trauma, such as visual, olfactory, or auditory information.

The experience of trauma within the SPAARS system works in a simple fashion characterized by Figure 5.1.

Ultimately, all trauma information-after proceeding through the different levels of schematic, propositional, analogical, and associative levels-are appraised at the schematic level, which gives rise to emotion in the face of current stimuli, and emotions can be generated in relation to past experiences.

At the center of the SPAARS model is a theory of emotions that proposes that emotions are tools used for the resolution of problems and the reaching of goals. If the problem faced by a human is a threat, then the emotion of fear is experienced, and the cognitive system that deals with current and future threat is engaged. Emotions are central cognitive orienting or organizing constructs that adaptively reorganize a person's cognitive system in various and different ways to deal with changes in the internal and external environments. When this process goes awry, disorder or pathology ensues.

Traumatic stimuli produce intense fear after being processed at the schematic level and are represented or stored in the analogical, propositional, and associative levels in the SPAARS model.

When posttraumatic processing of trauma information is processed at the various SPAARS levels but not successfully integrated, symptoms are produced. Trauma can challenge one's sense of self at the schematic level, for example. Trauma can result in the lack of integration between the different levels of the system.

Meaning at the schematic level is maintained by the processing of other-level information yet to be integrated. As long as the information is processed as incompatible or unintegrated, an individual will be in a constant state of fear activation.

Schematic Level

V Intense Fear

Traumatic Event

Analogical Level

Associative Level

Propositional Level

FIGURE 5.1 The SPAARS Model.

Foa's Integrated Emotion Processing Theory

Edna Foa and colleagues expanded upon the earlier theory of fear networks in a number of works (Foa & Meadows, 1998; Foa & McNally, 1996; Foa & Riggs, 1993; Foa & Rothbaum, 1998) by placing more emphasis on the disorganized nature of the traumatic memories. Dalgleish (2004) considers this later work as one of the most comprehensive cognitive theories of PTSD in the literature. There are three components to this model: memories, schemas, and posttraumatic reactions of self and others.

Posttraumatic memories are disorganized because of the disrupted and altered information processing at the time of the traumatic event or stressor. The disruption is a consequence of the intense peritraumatic emotions, which leads to what Dalgleish (2004) calls, "disorganized and unbalanced memory records." Research support for this has come from analyzing the narratives of trauma victims before and after treatment. The more organized trauma narratives were or are, the less symptom intensity and vice versa (Foa, Molnar, & Cashman, 1995; van Minnen, Wessel, Dijkstra, & Roelofs, 2002).

Another memory phenomenon involves the number of stimulus-danger associations stored in memory. A large network of information is tied to signs or signals of danger. This is akin to a stimulus overgeneralization process. Just about anything, then, can be associated with danger and set off an alarm. Trauma memories are also varied in the number of responses they possess. Nontrauma-fear-related memories do not have the same number of physiological, cognitive, and behavioral responses that trauma-related memories do. This is cited as possibly related to the trauma victim's subject experience of being out of control of him- or herself.

Traumatic stressors violate existing schematic knowledge similar to the types of violations outlined in Janoff-Bulman's (1992) work. Schemas related to a person's ability to cope and be safe and the general safety and predictability of the world are important. This process leads to a collection of intrusive and avoidance symptoms. There must, however, be a high discrepancy between pretrauma schemas and traumatic stressor-related information.

Finally, traumatic stressors and posttraumatic events can alter one's sense of self and others. The interpretation of symptoms, for example, can activate pretrauma schemas that exacerbate difficulties. Victims can develop views of themselves as weak or as failures. This leads to a vicious cycle that maintains PTSD symptoms. Also, unsympathetic responses from others or being blamed may also contribute to problematic schema development, such as schemas of incompetence.

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