Invited essay
A cognitive model of posttraumatic stress disorder

https://doi.org/10.1016/S0005-7967(99)00123-0Get rights and content

Abstract

Posttraumatic stress disorder (PTSD) is a common reaction to traumatic events. Many people recover in the ensuing months, but in a significant subgroup the symptoms persist, often for years. A cognitive model of persistence of PTSD is proposed. It is suggested that PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat. The sense of threat arises as a consequence of: (1) excessively negative appraisals of the trauma and/or its sequelae and (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualisation, strong associative memory and strong perceptual priming. Change in the negative appraisals and the trauma memory are prevented by a series of problematic behavioural and cognitive strategies. The model is consistent with the main clinical features of PTSD, helps explain several apparently puzzling phenomena and provides a framework for treatment by identifying three key targets for change. Recent studies have provided preliminary support for several aspects of the model.

Section snippets

Overview

When trying to conceptualise PTSD from a cognitive perspective, one is immediately presented with a puzzle. PTSD is classified as an anxiety disorder. Within cognitive models, anxiety is a result of appraisals relating to impending threat. However, PTSD is a disorder in which the problem is a memory for an event that has already happened. We suggest that this apparent puzzle can be resolved by proposing that persistent PTSD occurs only if individuals process the traumatic event and/or its

Delayed onset of PTSD

So far we have presented PTSD as a syndrome characterised by common initial symptoms, which persist in some individuals. While this is generally correct, there are individuals with persistent PTSD who report that they experienced few or even no symptoms in the first few weeks or months after the traumatic event and that the onset of PTSD did not occur till months or even years after the trauma. How does the model deal with delayed onset cases? In general, we assume that the delay occurs either

Treatment implications

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 three areas.

  • The trauma memory needs to be elaborated and integrated into the context of the individual's preceding and subsequent experience in order to reduce intrusive reexperiencing.

  • Problematic appraisals of the trauma and/or its sequelae that maintain the sense of

Summary and empirical support

It is suggested that PTSD becomes persistent when individuals process the trauma in a way which produces a sense of serious, current threat. The sense of threat arises as a consequence of: (1) excessively negative appraisals of the trauma and/or its sequelae and (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualisation, strong associative memory and strong perceptual priming. Change in the negative appraisals and the trauma memory are prevented by a

Acknowledgements

A.E. and D.M.C. are Wellcome Principal Research Fellows. We are grateful to Emma Dunmore, Melanie Fennell, Ann Hackmann, Freda McManus and Regina Steil for their collaboration, ideas and insightful clinical observations that are given as examples in this paper. They made many important contributions to the conceptualization of PTSD treatment outlined here. We thank Edna B. Foa for many inspiring discussions and her collaboration. Many thanks to Martin Conway and Chris Brewin for their

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