Ehlers & Clark (2000) A cognitive model of posttraumatic stress disorder

Question 1

wat is lastig aan het bekijken van ptsd van een cognitief perspectief

Answer 1

In understanding PTSD from a cognitive perspective, there’s a puzzle as it’s categorized as an anxiety disorder, and anxiety typically results from appraisals of incoming threat. However, PTSD involves memories of past events

Question 2

wat is de oplossing hiervoor

Answer 2

The proposed solution is that persistent PTSD occurs when individuals process the traumatic event in a way that creates a sense of serious current threat.

Question 3

two key processes contribute to this perception of serious current threat:

Answer 3

1. how individuals appraise the trauma and its consequences
2. the nature of the memory for the event and its connection to other memories

When the feeling of current threat arises, it triggers intrusions, reexperiencing symptoms, arousal, anxiety, and emotional reactions. The perceived threat then prompts actions and thoughts that aim to relieve immediate distress but unintentionally sustain the disorder by hindering cognitive change (in: nature of trauma memory and negative appraisals).

Question 4

natekenen model op pagina 14

Answer 4

echt doen

Question 5

appraisals contributing to a sense of current threat in ptsd involve aspects:

Answer 5

1. overgeneralization of the event: external (may perceive normal activities as more dangerous, may exaggerate the likelihood of future events). these appraisals do not only generate situational far but also contribute to avoidance behaviours that sustain the overgeneralized fear.
2. appraisals of personal characteristics: internal (how one felt or behaved during the event can lead to the long-term threatening implications)

Question 6

negative appraisal of the consequences of trauma, contributing to ptsd:

Answer 6

1. interpretation of initial symptoms (individuals may misinterpret symptoms after trauma as indications of permanent negative changes or threats to their well-being)
2. dysfunctional coping strategies (lead to emotions like anxiety, depression, or anger.
   individuals adopt dysfunctional coping strategies like active thought suppression that paradoxically enhance PTSD symptoms).
3. uncertain reactions from others (family and friends may avoid discussing the events, which can lead to isolation and estrangement)
4. objective uncaring reactions (individuals may be uncaring, rejecting or critical of trauma victims. this can lead to internalizing blame, feel unworthy or unlikeable, fear impaired relationships).
5. long-term effects of trauma (trauma can have long lasting effects on health, appearance, education/work and financial situations. people may interpret these as permanent negative changes, reinforcing the sense of current threat).

Question 7

Main emotions depend on specific appraisals:

Answer 7

• Perceiving danger leads to fear
• Violations of personal rules lead to anger
• Responsibility for the event leads to guilt
• Violation of internal standards leads to shame
• Perceived loss leads to sadness

Question 8

Most patients with PTSD often experience a range of negative emotions due to:

Answer 8

• different negative appraisals activating at different times
• varying in degrees of belief of those appraisals

Question 9

what is the memory of the traumatic event like

Answer 9

people with ptsd often struggle to intentionally recall a complete memory of the traumatic event. however, they frequently experience involuntary intrusive memories triggered by external cues, reexperiencing aspects of the event vividly and emotionally.

poor intentional recall vs. vivid unintentional reexperiencing

Question 10

hoe kan deze contradictie uitgelegd worden

Answer 10

• reexperiencing mainly consists of sensory impressions rather than thoughts
• sensory impressions feel like they are happenening now, not as memories (the emotions and physical reactions are the same, without the usual awareness of remembering seen in regular memories)
• people with ptsd reexperience original emotions and sensory impressions, even if they later learn new information that contradicts the initial impressions or know the impressions were not true
• individuals may feel emotions or sensations linked to a traumatic event without actually recalling the event itself (affect without recollection)
• the involuntary reexperiencing of an event can be triggered by various stimuli and situations, often including cues thtat may not have a direct connection to the event, but were associated with it in time

Question 11

voorbeeld affect without recollection

Answer 11

a rape survivor might suddenly feel extreme anxiety in a restaurant without consciously remembering the traumatic event, only later realizing that it was triggered by the presence of a man resembling the perpetrator

Question 12

It is proposed that the poor intentional recall and the vivid unintentional reexperiencing is due to….

Answer 12

the way the trauma is encoded and laid down in memory

Question 13

2 ways memories are usually retrieved:

Answer 13

1. through higher-order meaning-based strategies (recalling)
2. through direct triggers by associated stimuli (smells or music)

Question 14

cues soorten

Answer 14

Physical:
* the shape of a person
* spatial details
* smells
* specific lighting patterns
* phrases spoken in a certain tone.

Emotional:
* feeling helpless
* feeling trapped

Other internal cues:
* touch in a specific body area
* body awareness signals
* posture

Question 15

two types of processing

Answer 15

• conceptual processing: normal memory processing organizes memories by themes and time periods, reducing unintentional retrieval during daily tasks
• data-driven processing: processing the sensory impressions. in PTSD, traumatic memories aren’t properly processed (in time, place and in other memories) making it hard to remember them intentionally and making it easy to be triggered by related cues

Question 16

welke retrieval route is related to welke processing

Answer 16

conceptual processing: enhances the first retrieval route (through higher-order meaning-based strategies) and inhibits the second (direct triggers)

data-driven processing: enhances the second route (direct triggers) and inhibits the first (higher order meaning-based)

Question 17

strong stimulus-stimulus and stimulus-response associations

Answer 17

In PTSD, strong associations between traumatic memories and stimuli make it more likely for related cues to trigger other cues and to trigger involuntary recall of
the event and emotional responses.

E.g. someone who was idnapped not only gets
triggered by someone knocking on the door (associated with the kidnappers coming in) but also gets triggered by approaching footsteps (that preceded the knocking on the door)

Question 18

2 key aspects of this conditional learning contribute to PTSD persistence:

Answer 18

1. It helps predict danger based on specific stimuli linked to the traumatic event (which is seen as beneficial for the individual with PTSD).
2. Memory retrieval is triggered unconsciously, making individuals unaware of the cues causing the reexperiencing. Failure to spot the origin of the reexperiencing symptoms makes it difficult for the patient to learn that there is no present danger when exposed to the triggers

Question 19

Strong perceptual priming:

Answer 19

Strong perceptual priming for stimuli connected to a traumatic event leads to a lower threshold for noticing these cues. This heightened sensitivity is due to poor stimulus discrimination in implicit memory.

E.g., a person involved in a nighttime car crash
may vividly recall headlights approaching hen exposed to a patch of bright sunlight on their lawn.

Question 20

The relationship between traumatic memories and individuals’ appraisals is reciprocal:

Answer 20

1. In PTSD, recalling the trauma is influenced by biased appraisals, leading to selective retrieval of information consistent with these appraisals. This selective recall reinforces existing appraisals and hinders change.
   E.g., a patient who believed nobody cared about her during an accident recalled unfriendly responses but not the attempts to help her.
2. Inability to remember trauma details can be interpreted negatively.
   E.g., memory problems may be seen as a sign of serious mental issues or responsibility for the event.
3. Disturbed memory organization in individuals can threaten their self-view, resulting in disorientation and less-filtered, cue-driven recall of the traumatic event.
   E.g. this is comparable to someone in a new town initially mistaking people with familiar faces until adjusting to the new environment

Question 21

Maladaptive behavioural strategies and cognitive processing styles:

Answer 21

Patients with PTSD have various strategies to control perceived threats and accompanying symptoms. Unfortunately, these strategies maintain PTSD through:

1. Directly producing PTSD symptoms
2. Preventing change in negative appraisals of the trauma and it’s consequences
3. Preventing change in the nature of trauma memory

Question 22

Maladaptive cognitive strategies that increases PTSD symptoms directly:

Answer 22

1. thought suppression (if patients try hard to push thoughts about the trauma out of their
   mind, this will increase the frequency of unwanted intrusive recollection)
2. behaviours used to control ptsd symptoms may increase others (attempt to prevent nightmares by going to bed very late or getting up very early may increase symptoms of concentration, irritability and alienation)
3. selective attention to threat cues

Question 23

Maladaptive strategies that prevent a change in the appraisal of the traumatic event or its consequences are:

Answer 23

Safety behaviours: These are actions individuals take to prevent or minimise anticipated further catastrophes.

E.g., someone who has been assaulted at home might always keep a knife by their bed to reduce the risk of another intruder harming them.

Question 24

Among the maladaptive strategies that prevent a change in the nature of the trauma memory is:

Answer 24

1. Actively trying not to think about the event.
   Individuals with PTSD try to keep their mind constantly occupied with other things (e.g. cleaning) or they try to think about the event in a non-emotional way
2. Dissociation (another cognitive response
   during trauma reminders) is not fully understood but also hinders recovery.
   Derealization, depersonalization, and emotional numbing during dissociation may obstruct the development of the trauma
   memory and its incorporation into one’s memory.

Question 25

Maladaptive strategies that prevent change
in both negative appraisals of the trauma and its consequences and the nature of the trauma in memory:

Answer 25

• Avoiding reminders of trauma: Reminders often serve as cues for details, and avoiding them hinders the development of a more comprehensive trauma memory linked to its context.
• Using alcohol or medication to
  manage anxiety.
• Abandoning or avoid activities they enjoyed before the trauma (such as sports, hobbies, or socializing), hindering positive changes in appraisals and preventing the reorganization of their memory for a continuous self-view.
• Rumination about the trauma and its consequences,

Question 26

cognitive processing that affects appraisal

Answer 26

mental defeat: the perceived loss of all psychological autonomy, accompanied by the sense of not being human any longer

Question 27

cognitive processes that affect the nature of the trauma memory

Answer 27

• the quality of processing at encoding (should be more conceptual than data driven)
• difficulty to incorporate traumatic event with self-view
• not having enough cognitive capacity to decide that some threatening aspects of the trauma are not true

Question 28

two ways in which ptsd have a delayed onset

Answer 28

1. When a later event assigns a more threatening meaning to the trauma
2. When potential reminders of the trauma become relevant later

Question 29

anniversary reactions

Answer 29

Many people with persistent PTSD often experience worsened symptoms around the anniversary of the traumatic event. This can be attributed to due to the facts that:
* During anniversaries, individuals face external reminders
* Internally, they create cues by reflecting on their lives before the trauma and recalling feelings and experiences on the day it occurred.
* Anniversaries also serve as markers for negative appraisals of symptoms, such as feeling inadequate for not overcoming the trauma

Question 30

frozen in time

Answer 30

ptsd often makes individuals feel trapped in the past, hindering them from moving forward or starting anew.

3 sources:
1. related to appraisals of the trauma and its consequences: they believe they are permanently changed for the worse, and belief their former life goals are unimportant or irrelevant because another catastrophe is going to happen soon.
2. continually reexperiencing sensations and emotions they had at the time of the trauma in their original form, disconnecting them from current reality
3. giving up or avoiding activities that were important to the person before the traumatic event contributes to the sense that time has stood still at the point of the traumatic event

Question 31

sense of impeding doom

Answer 31

Intrusive memories of the traumatic event are often accompanied by a sense of “worse is to come”. The model explains this is by the nature of the trauma memory:
* In PTSD, sensory information and emotions are recalled from memory without the time-perspective of “remembered” emotions, causing a perception of future threat.
* Intrusive memories may feel like “warning signals”

Question 32

No benefit from talking/thinking about the trauma

Answer 32

People with PTSD often express that constantly thinking and talking about the trauma hasn’t brought relief. This may be due to the way they approach these thoughts and conversations:

• Rumination Instead of Reflection: Thoughts often involve “what if…” questions rather than a detailed reflection on the actual events, feelings, and thoughts during the trauma.
• Nonemotional Reporting: Talking is often done in a detached, nonemotional manner, resembling a police report, with the most distressing aspects left out.

-> This hinders proper access to the meaning
of the event and its contextualization.

Question 33

treatment implications:

Answer 33

When people talk about recovering from a traumatic experience, they often use the metaphor: “I have put it in the past”. The current model suggests that in persistent PTSD, putting the trauma into the past requires change in 3 areas.
1. The traumatic memory must be thoroughly understood and connected to the person’s past and future experiences
2. Change negative appraisals of the trauma and its consequences that contribute to a sense of current threat.
3. Stop using unhelpful behaviors and thoughts that hinder memory processing, worsen symptoms, or prevent reassessment of negative interpretations

Question 34

cognitive-behavioural interventions lijst

Answer 34

• identify cognitive themes (post-traumatic cognitions inventory (PTCI), reflect on the worst aspects and most painful moments of the trauma
• explore hotspots (parts of the memory causing strong distress)
• examine intrusive elements (explore intrusive images and moments of dissociation)
• understand emotional components (identify predominant emotions (guilt, anger, shame))
• investigate post-trauma experiences (explore distressing beliefs since the event, explore beliefs about the symptoms, future and others’ behaviours)
• address delayed onset cases (identify events altering the meaning of the original trauma)
• evaluate behavioural and cognitive coping strategies (investigate avoidance strategies, understand how patients deal with intrusions and their beliefs about dwelling on the trauma, explore rumination and its content)
• characterize trauma memory (address gaps, examine sequence of events and confusion about it, explore here and now qualities during intrusions)
• prepare for reliving sessions (some details can become clearer during reliving/reexperiencing)

Question 35

rationale for treatment: 3 main points

Answer 35

1. Explaining that symptoms of PTSD, like intrusive memories and heightened arousal, are common reactions to unusual events. The therapist emphasizes this by discussing the specific symptoms experienced by the patient.
2. Suggesting that the ways the patient has been coping with the traumatic memory might have been helpful for dealing with other stressors but are now maintaining their PTSD symptoms.
3. Fully processing the trauma and addressing the factors that are keeping the symptoms going.

Question 36

metafoor voor deze treatment

Answer 36

A crucial part of the treatment involves talking and thinking about the trauma in detail. Analogies like ‘a messy closet that wouldn’t close unless it is organized’ are used to illustrate this process.

Question 37

Thought suppression experiment

Answer 37

To demonstrate the drawbacks of trying to suppress intrusive thoughts or rumination, a therapist might conduct a simple experiment with the patient:

1. the patient is asked not to think about a specific thing (e.g. a pink elephant)
2. despite their best efforts, most people find it challenging to avoid thinking about the elephant

The therapist then discusses this outcome, highlighting that suppressing thoughts often leads to more frequent intrusions. The patient is assigned homework to observe and allow intrusive thoughts without trying to push them away, similar to watching trains pass through a station. This often reduces intrusive thoughts and lessens the fear of impending doom, insanity or loss of control.

Question 38

reclaiming one’s life

Answer 38

Patients with PTSD often feel stuck in the past, leading them to abandon once-meaningful activities. To counter this, they are encouraged to reintroduce former activities, even through small changes, to help them move forward. If physical effects of trauma hinder the original activity, alternatives are explored. Planning the reactivation involves discussing problematic beliefs that may hinder compliance

Question 39

reliving with cognitive restructuring

Answer 39

Reliving the traumatic event is a crucial component of many PTSD cognitive-behavioral programs. This can involve describing the experience verbally in therapy or writing a detailed account.

Question 40

3 ways in which reliving with cognitive restructuring can help

Answer 40

In this model, reliving serves multiple purposes:
* It aids in expanding and contextualizing the trauma memory,
* It helps identifying individualized appraisals and “hot spots”
* It functions as a behavioral experiment for those fearing loss of control or other negative outcomes from detailed trauma reflection.

Question 41

patients who are particularly likely to require extensive verbal and imagery cognitive restructuring are those who…

Answer 41

• experience anger, guilt or shame as main emotion
• interpret their behaviour or emotions during the event as showing something negative about themselves
• experienced violence over a prolonged period of time

for some people in this category, extensive cognitive restructuring may be requierd before imaginal reliving can be beneficial.

Question 42

how is reliving expected to help memory elaboration

Answer 42

• it connects previously unconnected elements of the traumatic experience, giving them context and reducing the chance of triggering isolated memories
• it helps retrieve memory elements that are hard to access otherwise, leading to immediate changes in problematic appraisals
• patients may incorporate post-traumatic information during reliving, correcting impressions and lessening current threat perception
• reliving helps discriminating between the traumatic event and safe situations
• verbalizing sensory cues during reliving may make it harder to retrieve original sensory impressions from memory

Question 43

in vivo exposure

Answer 43

exposing patients to avoided reminders in real life situations and activities. this can help them accept the trauma as past. revisiting trauma aids in establishing a time perspective and correcting misconceptions. overgeneralized fears and appraisals of trauma consequences are also challenged through exposure, providing corrective experiences that reshape patients’ beliefs.

Question 44

how are patients trained to elaborate the trauma memory

Answer 44

1. identify triggers
2. discuss similarities and differences between trauma-related triggers and current experiences
3. emphasize dissimilarities to distinguish between past trauma and present contexts

Question 45

imagery techniques

Answer 45

help elaborate and change the meaning of traumatic memories and allows patients to explore unchosen actions and consider spiritual perspectives