Ulrich Schnyder and Marylène Cloitre (eds.)Evidence Based Treatments for Trauma-Related Psychological Disorders10.1007/978-3-319-07109-1_3

3. Psychological and Social Theories of PTSD

Mirjam J. Nijdam¹ and Lutz Wittmann²

(1)

Department of Psychiatry, Center for Psychological Trauma, Academic Medical Center at the University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, The Netherlands

(2)

International Psychoanalytic University Berlin, Stromstraße 3, 10555 Berlin, Germany

Mirjam J. Nijdam (Corresponding author)

Email: m.j.nijdam@amc.uva.nl

Lutz Wittmann

Email: lutz.wittmann@ipu-berlin.de

3.1 Introduction

Psychological theories have been developed to explain why certain trauma survivors go on to develop PTSD and others do not. These theories try to capture what happens at the level of the trauma survivor’s personal experiences, in terms of thoughts, memory, emotions, behaviours, and underlying processes of which the person is unaware. Symptoms of PTSD in DSM-5 include recurrent involuntary and intrusive memories of the trauma, flashbacks that make the person feel like he or she is experiencing the trauma again, inability to recall key features of the trauma, and impaired concentration (American Psychiatric Association 2013). Because these symptoms are linked to memory functioning and the way the trauma is processed, PTSD has been termed a disorder of memory by various theorists (Brewin 2003; McNally 2003; van der Kolk 2007). Trauma-focused psychotherapies could also be called memory-focused psychotherapy for PTSD, because patient and therapist work with the memory of the trauma (Grey and Holmes 2008).

Psychological theories are also essential to understanding the working mechanisms of psychological treatments for PTSD. It can sound quite counterintuitive that imaginal exposure to the traumatic memory works, as some memory theories predict that repeated exposure to a memory would only strengthen it (f.i. Crowder 1976). In the first part of this chapter, we will successively focus on theories of fear conditioning, dual representation theory, cognitive theory and ‘hotspots’, and psychodynamic theories. We will first discuss the most important concepts used by these theories and then focus on their accounts of natural recovery from PTSD and their proposed working mechanisms for psychological treatments. In the second part of this chapter, we will outline PTSD from a societal perspective and discuss the most important ideas in this realm. Case examples will provide illustrations of important concepts of these theories.

3.2 Fear Conditioning Theories

The overarching idea of these theories is that a traumatic event is stored in a way that hinders the person’s recovery from the trauma and from PTSD. This can, for instance, be apparent in recollections of the trauma that keep the person from maintaining his or her daily routines and vivid nightmares from which the person awakens, reducing the individually necessary amount of sleep the person needs. In the elementary version of these theories, two processes were hypothesized in the process that led to PTSD symptoms after having experienced a traumatic event. Mowrer’s two-factor theory (1960) assumes that these processes play a role in all anxiety disorders, and this theory has been further elaborated for PTSD by Keane and colleagues (1985). A classical conditioning process is hypothesized to be crucial in the development of PTSD. This classical conditioning process holds that previously neutral stimuli present at the time of the traumatic event (conditioned stimuli, such as the tunnel where an accident happened) become fear-laden through their coupling with the trauma, for instance, the accident itself (termed the unconditioned stimulus). When a person encounters a conditioned stimulus such as the tunnel again, it would evoke the memory of, for instance, the car that was shred to pieces and the people who were severely wounded in the accident. An operant conditioning process is proposed to be responsible for the maintenance of the PTSD symptoms in the longer run. This operant conditioning process would involve people avoiding thinking about or being reminded of the traumatic event, because this memory is painful and evokes anxiety and tension. Avoiding the fear-conditioned stimuli or thinking of the incident itself in one’s mind would be reinforced by a short-term decrease of fear or even the absence of fear and tension. One can imagine how this may be for an accident survivor who may want to avoid the tunnel in which the accident took place altogether or try to block the thoughts of the traumatic incident when it is necessary to drive through the tunnel because he has no other option. However, such avoidance would make the person even more anxious and tense to think of the traumatic event in the future and thus reinforce the fear responses in the long run.

Lang’s theory (1979, 1985) assumes that frightening events are stored in a broader cognitive framework and that they are represented within memory as interconnections between nodes in an associative network. These networks function as a kind of prototypes for recognizing and coping with meaningful situations. Three types of information were proposed: stimulus information about the trauma, such as sights and sounds, information about the emotional and physiological response to the event, and meaning information (most importantly about the degree of threat). These nodes are interconnected, so if the person encounters one sort of information belonging to the traumatic event, the other modes of information would be activated automatically. As soon as sufficient elements of the network are activated, the whole network of fear is activated together with the subjective experience and the corresponding behaviours. Lang proposes that fearful memories are easily activated by ambiguous stimuli, which are in some respect similar to the content of the original anxiety-provoking memory. PTSD may then be explained as a permanent activation of the fear network because of the very tight connections in this kind of fear network and the very strong emotional and physiological responses. Knowledge about the traumatic experience can change by strengthening associations between a certain emotional network and other incompatible networks. If the above-mentioned accident survivor approaches many tunnels and experiences that physiological responses such as panic do not occur, this response is incompatible with anxiety and avoidance.

Foa’s emotional processing theory (1989, 1998) draws on these principles but emphasizes that the representation of traumatic events in memory is different from that of ‘normal’ events. An assumption made by this theory is that traumatic events violate the basic concepts of safety that people hold. A central concept in this theory is the fear network, the cognitive representation of fear that includes both emotional reactions and ongoing beliefs about threats in the environment. Foa and colleagues hypothesize that activation of one node (the place of the accident) would automatically and selectively evoke the fear node and behavioural and physiological responses (such as sweating and heart palpitations) that coincide with very frightening events. Activation of the fear network could be caused by a large number of environmental cues and would have a low threshold to be activated. A person with PTSD would notice this activation in terms of hypervigilance to trauma cues, information of the traumatic experience entering consciousness and re-experiencing parts of it, having very strong physiological responses when being reminded of the trauma, and attempting to avoid and suppress intrusions. Updates to this theory have focused on the role of pre-trauma views and vulnerability for PTSD as well as negative appraisals of responses and behaviours which could exacerbate the perception of incompetence (Foa and Rothbaum 1998; Brewin and Holmes 2003; Foa et al. 2007). Pre-trauma views that are more rigid (either rigid positive views or rigid negative views) would lead to increased vulnerability for PTSD. Rigid positive views about the self as extremely competent and the world as extremely safe would be contradicted by the trauma. Rigid negative views about the self as extremely incompetent and the world as extremely dangerous would be confirmed by the traumatic event. These rigid negative beliefs (or the shattering of the positive ones) make a person likely to interpret many situations or people as harmful and overgeneralize danger. Emphasis is also placed on beliefs present before, during, and after the trauma, which may lead to negative appraisal of one’s reactions to the trauma and exacerbation of feeling incompetent or feeling very much in danger.

Foa and Rothbaum (1998) further suggest that trauma memories can be reactivated and changed by incorporating new information. Natural recovery would mean that this fearful memory would be integrated with the rest of a person’s memories, and the overly strong reactions need to be weakened for this. This could be achieved by repeated exposure to the fearful places and memories and by integrating information that is inconsistent with the fearful character of the acquired traumatic memory (for instance, driving through the same tunnel and not being in an accident). Foa et al. (1989) assume that PTSD will persist if this exposure to all the fearful elements of the memory does not take place sufficiently or long enough for anxiety to habituate. In that case, only some associations are weakened and others stay intact. Excessive arousal or thinking errors and simply the strong tendency to avoid re-exposure are examples of ways in which this process does not take place in an optimal fashion. Trauma survivors may then continue to believe that the world is threatening.

The treatment method that is rooted in this theory, prolonged exposure therapy (Foa and Rothbaum 1998; Foa et al. 2007), has proven to be very effective and is recommended in various treatment guidelines as treatment of choice for PTSD (NICE 2005; Foa et al. 2008). Repeated exposure to the trauma memory is applied in this treatment with the aim of achieving fear extinction. For emotional processing to occur, Foa and colleagues think that it is essential that survivors are emotionally engaged with their traumatic memories, that they articulate and organize their chaotic experience, and that they learn to develop a balanced view of the world – to come to believe that the world is not a terrible place, despite the trauma (Foa and Riggs 1995; Foa and Street 2001). Effective processing changes the unrealistic associations and erroneous cognitions are corrected (Foa et al. 2007).

Case Example

A woman who had survived a plane crash in which the airplane was set on fire during landing was very frightened to fly again. For her work, she used to fly every week and she tried to continue to do this, but she panicked the moment the doors closed for take-off and urgently asked to get out. She spoke with pilots who were very understanding and said that they would never fly again if they had experienced what she had been through. This reinforced her fear of flying. Repeated exposure to the memory of what had happened and repeated focusing on the details of the worst moments of the crash in which she thought she was going to die reduced the anxiety that this memory evoked in her. This helped her overcome her fear of stepping into a plane, and she noticed that the panic reactions subsided after the take-off and after the landing.

3.3 Dual Representation Theory

Dual representation theory of PTSD (Brewin et al. 1996, 2010; Brewin 2008) assumes that there are two kinds of memory representations that play a role in PTSD. In this model, the flashbacks experienced by PTSD patients are assumed to be the consequence of the enhanced encoding of certain aspects of the traumatic event called sensation-near representations (S-reps). In earlier versions of the theory, these were called situationally accessible memory (SAM) to emphasize that these aspects can automatically be activated by triggers that the person encounters. This explains why a PTSD patient with flashbacks of being stabbed with a knife feels as if the trauma is occurring in the present, because the memory is primarily sensory and lacks a spatial and temporal context. This memory representation contains information that has not yet been processed by higher cognitive functions, but consists of information coming from lower perceptual processes and the direct autonomic and sensorimotor responses of the person. They are assumed to be processed in parts of the brain that are specialized for action in the environment, specifically the dorsal visual stream, insula, and amygdala. The information is closely and directly connected to the traumatic event itself and with the strong emotional reactions of the person when it happened. In case of the survivor of the stabbing incident, these memories would for instance be very much coupled to pain in the place where the knife once entered the survivor’s body. Moreover, the model assumes that there is an impaired encoding of the material in parallel contextualized representations (C-reps). In earlier versions of the theory, these were termed the verbally accessible memory system (VAM) to indicate that the person had consciously processed these parts of information and could communicate about these with other people. Contextualized representations are assumed to be processed in the ventral visual stream and in the medial temporal lobe. Personal meanings, implications, and consequences of the traumatic event have been thought through, and an association has been made with previous and other experiences about which knowledge is present in the autobiographical memory. These representations could inhibit the re-experiencing symptoms but function poorly in PTSD. Retrieving material from the contextualized representations can be the result of a conscious search strategy (‘where was I at the time of the stabbing incident, and with whom?’) but also be automatically activated by cues that remind the person of an incident. Because attention is very focused on danger and survival in case of a traumatic event and because this coincides with high arousal, the contents of the contextualized representations will be limited.

According to Brewin (2008), this preferential encoding in PTSD may be a product of peri-traumatic dissociation reactions and the prefrontal cortex temporarily going ‘off-line’ in response to a level of stress that exceeds the person’s coping. Flashbacks would then provide an initially adaptive pathway to natural recovery. They are an opportunity to encode the information that is lacking into contextualized representations and strengthen connections between C-reps and S-reps, to create a new memory representation of the traumatic event with a spatial and temporal context. The awareness that the trauma has happened in the past would then also decrease the need for sensory memories in response to trauma cues. Dual representation theory suggests that the process of re-encoding from S-reps to C-reps does not take place in PTSD, leading to persistent and intense flashbacks and nightmares and to a poorly functioning verbal memory.

Dual representation theory also offers explanations for how trauma-focused cognitive behavioural therapy could work (Brewin 2005). Brewin assumes that trauma treatment involves both the image-based S-reps and the more verbally oriented C-reps. According to this theory, a form of imaginal exposure reduces re-experiencing symptoms, and cognitive restructuring techniques target beliefs that the person has about himself or herself and the world. When the trauma survivor deliberately maintains attention on the content of the flashbacks and no longer tries to avoid them, information that is only present in the S-reps is presumed to be re-encoded in C-reps, and connections between S-reps and C-reps are strengthened. Trauma survivors will then be able to place their memory in the past and to recognize that the threat is no longer present. This reduces the flashbacks and nightmares and thereby leads to PTSD symptom reduction. The different contents of memory representations and the re-encoding during treatment can be recognized in the following case example.

Case Example

A nurse was attacked by a patient at a mental health admission facility. The bathroom door of the patient’s room had been left open by colleagues, but this had not been communicated to her. The access to the bathroom caused the psychotic patient to be within reach of an aftershave bottle, which he had destroyed. He used the broken bottle to stab her in the face when she entered his room to check on him. He entered into a fight with her. He was huge and she was not strong enough to resist him. She felt like she was left to her fate and that he would kill her. This incident had left a scar on her cheek and nose, which reminded her of the dangerous situation she had been in. In the exposure treatment, she remembered two parts of the trauma story again that she had forgotten about. One part was the moment that she was able to press her emergency pager. She realized that she had been able to actively cope with the situation and that this had made her colleagues rush to the room and prevent worse things from happening. The other part she remembered in an exposure session was the moment her colleagues gathered around her and she first realized what had happened. She remembered that one of her female colleagues held her and this made her cry in the session, which had not happened since the incident. Later, she also realized that the patient had a severe mental condition and that the attacker’s victim could have been anyone; she was no specific target. This mitigated the pain she felt over the scars. When she was confronted with the patient in court, she realized that he was a normal-sized man contrary to what she thought she had seen before.

3.4 Cognitive Theory and ‘Hotspots’ in Trauma Narratives

3.4.1 Cognitive Theory of PTSD

Some emotional responses of trauma survivors depend on cognitive appraisal. Cognitive factors, such as expectancies and the individual’s amount of control over the situation, have been elaborated by Ehlers and Clark (2000) in their model of PTSD. They propose that experiencing extreme stress, which depends on the person’s appraisal of the threat, is an essential factor in the occurrence of acute stress reactions, which display emotional, behavioural, and biological effects. Failure to effectively regulate this acute reaction may result in an ongoing dysregulation, which may ultimately lead to posttraumatic stress symptoms. Ehlers and Clark describe that pathological responses to traumatic events occur when the trauma survivor processes the trauma in a way that produces a sense of current threat. This sense of current threat can be outward-focused to an external source of threat (for instance, that a trauma survivor feels that she cannot trust other people’s actions) or inward-focused as an internal threat to the self and the future (e.g. when a trauma survivor feels that her body has been ruined forever by a sexual assault). Negative appraisals about danger, violations of boundaries, and loss are thought to be responsible for the range of emotions experienced by trauma survivors with PTSD.

Trauma survivors with PTSD can thus experience an ongoing sense of threat either because they fear that the trauma will recur or because they believe they are not able to cope with their emotions. Furthermore, the nature of the trauma memory itself is different from that of an ordinary memory. Therefore, another possible reason for the ongoing sense of threat is that the trauma memory is inadequately integrated with the person’s broader autobiographical memories and beliefs. This means that the person has the feeling that a traumatic event will occur more frequently, that another robbery will take place or that another plane crash will occur. Situations that are in some respect similar to the traumatic event may evoke a strong sense of threat. This usually happens in an unintentional, cue-driven manner. Similarly to Brewin’s dual representation theory, Ehlers and Clark describe that the memory of the trauma is poorly elaborated and does not have sufficient context in terms of time and place. An important distinction in Ehlers and Clark’s theory is the difference between data-driven and conceptual processing. Data-driven processing is focused on sensory information, and conceptual processing on the meaning of the situation, organizing the information, and placing it in the appropriate context. According to Ehlers and Clark, conceptual processing facilitates integration of the trauma memory with autobiographical knowledge, whereas data-driven processing leads to perceptual priming and difficulty to retrieve the trauma memory intentionally. Flashbacks in this model are presumed to be the result of enhanced perceptual priming, which is a reduced perceptual threshold for trauma-related stimuli.

Ehlers and Clark also identified many coping strategies that play an important role in the onset and maintenance of PTSD. Behavioural coping strategies include active attempts to suppress unwanted thoughts, use of alcohol and medication to control one’s feelings, seeking distraction, avoidance of trauma reminders, and adoption of safety behaviours. Cognitive coping strategies that play a role are persistent rumination, dissociation, and selective attention to threat cues.

Case Examples

Several aspects of Ehlers and Clark’s model can be illustrated by the example of politicians under terrorist threat who have to live under strict protective measures (Nijdam et al. 2008, 2010). Politicians who received death threats and viewed them as not serious or not dangerous were almost free from stress reactions, whereas the politicians who took them very seriously had more stress responses and were disturbed by their responses to the situation. Their own assessment of the danger or threat proved to be very important in whether stress reactions occurred or not. Experiencing the situation as high risk or being extremely alert to signals that could indicate danger reinforced their perception of being under threat. Furthermore, some politicians also indicated that they suddenly started suspecting that people with a certain appearance were planning a terrorist attack, without having any real evidence for such a suspicion.
An explicit form of negative appraisal is the concept of mental defeat, defined by Ehlers and colleagues (2000) as ‘the perceived loss of all autonomy, a state of giving up in one’s own mind all efforts to retain one’s identity as a human being with a will of one’s own’. The inability to influence one’s own fate is a risk factor for very negative self-appraisals. After several life-threatening car accidents with permanent damage to his back and knees and after the crib death of his daughter, a trauma survivor expressed that he now felt ‘as if the system is broken’. He was afraid that the stress of these accidents had been too much for his body to bear and that he would totally break down. Stressful years at work and in private life added to this perception. When he was paged for his work in case of an emergent dike burst, this triggered recollections of the accidents. When he encountered the sentence ‘It is not safe to live’ in a book, he noticed that he completely agreed with this statement and this frightened him very much.

3.4.2 ‘Hotspots’ in Trauma Narratives

Ehlers and Clark developed cognitive therapy for PTSD, which is a highly effective treatment (Bradley et al. 2005). In this therapy, negative appraisals and cognitions are investigated and replaced by appraisals and cognitions that are more adaptive. Ehlers and colleagues also continued to study intrusive memories and found that these mainly represented stimuli that were present shortly before the moments of the trauma with the greatest emotional impact (Ehlers et al. 2002). They called these stimuli ‘warning signals’, because they alert the person to danger if encountered again. These stimuli are logically connected with a sense of current threat and are often re-experienced. Ehlers and colleagues (2004) developed a therapeutic strategy in which the intrusions lead the therapist to the moments with the greatest emotional impact, also called ‘hotspots’. In trauma-focused cognitive behavioural therapy, they assume that it is essential to focus on hotspots and change their meaning, in order to lead to a decrease in PTSD symptoms.

It is interesting to note that cognitive behavioural therapies of PTSD have seen this condition primarily as an anxiety disorder and much attention has been directed to optimal treatment of anxiety responses. The first case series on hotspots were important, because they showed that a range of emotions are often associated with these peak emotional moments in the trauma story. Anger, grief, shame, and guilt were shown to often be associated with hotspots (Grey et al. 2001, 2002), next to the typical emotional responses of anxiety, helplessness, or horror. This led Ehlers and colleagues (Ehlers et al. 2004) to believe that imaginal exposure functions not only to ensure emotional habituation but to identify the hotspots in the trauma story and use these as a starting point for cognitive restructuring. By this combination of techniques, new information can be added while reliving the trauma memory, which reduces the level of current threat. This technique was also elaborated by Grey and colleagues (2002), who, in an elegant way, combined imaginal exposure and cognitive restructuring for the broad spectrum of the emotions they found in hotspots. The way hotspots are addressed in imaginal exposure may be important for symptom reduction in trauma-focused psychotherapy (Nijdam et al. 2013).

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