Psychological theories

Psychological explanations of re-experiencing symptoms

Psychological theories have offered two major explanations for the re-experiencing symptoms following traumatic stress, characteristics of the trauma memory, and the effect of trauma on basic beliefs about the self and the world. Foa and colleagues (2,21) suggested that PTSD is characterized by a pathological network in memory that is particularly large and easily triggered. It contains many stimulus propositions erroneously linked to danger, causing fear responses to harmless stimuli associated with the traumatic event in memory. Ehlers and Clark(22> suggest that re-experiencing occurs because the trauma memory is inadequately linked to its context in time, place, and other autobiographical memories. Stimuli resembling those present during the traumatic event can thus trigger vivid memories and strong emotional responses that are experienced as if the event was happening right now. Brewin et al. (23) postulated that dual representations of the trauma are formed in memory. The first, termed verbally accessible memory, contains the conscious recollection of the trauma. The second memory representation, termed situationally accessible memory, which cannot be deliberately accessed, comprises sensory, physiological, and motor aspects of the trauma in the form of codes that enable the re-experiencing of the original experience.

Horowitz(24,) explained re-experiencing symptoms as the result of a slow process that helps the traumatized person to adjust their inner models (schemas) of the self and the world to the traumatic experience. Until this process is completed, the information related to the traumatic event is thought to be held in active memory and thus intrudes into consciousness. Similarly, Janoff-Bulman(25) proposed that traumatic events 'shatter' previously held beliefs (for instance, 'The world is a safe place'), and that post-trauma adjustment requires rebuilding basic beliefs about the self and the world. Traumatic events can not only shatter basic beliefs, but also confirm pre-existing negative beliefs.(2,26,)

Dissociation and other processes that impede recovery

Psychological models of post-trauma reactions concur that recovery is thought to require 'working through' the trauma memory—in other words, going through the experience again in one's own mind, understanding the meaning of the event, distinguishing which of the stimuli that were present at the time the trauma are dangerous and which are innocuous, and readjusting basic beliefs about the self and the world.

Horowitz(24,) suggested that the normal process of recovery involves working through the traumatic experience in a graduated manner, i.e. the individual uses protective cognitive mechanisms such as denial to prevent becoming overwhelmed by the experience. Psychological models concur in that the excessive use of such avoidant strategies (e.g. trying not to think about the trauma, efforts to push intrusive memories out of one's mind, ruminating about how the trauma could have been avoided) prevents recovery/2. ,22,24) There is preliminary empirical evidence supporting this hypothesis.(2 2 and 29>

The cognitive mechanism that has received the most attention in relation to acute stress disorder is dissociation, as reflected in the DSM-IV criteria. It has been argued that dissociation minimizes the adverse emotional consequences of trauma by restricting awareness of the experience to avoid overwhelming fear and loss of control.(1.4) Dissociation is thought to prevent recovery because it prevents the integration f the traumatic experience into existing schemas (30) and it prevents the full activation of the trauma memory which is thought to be necessary for its modification. (31> In line with these hypotheses, dissociation during or immediately after a traumatic event predicts PTSD.(1,2 ,32)

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