IB Docs (2) Team
Cognitive approaches to PTSD
The role of schema in PTSD
Schema are mental representations that help us to understand the world around us. They also act as filters to help us interpret what is happening to us. With regard to PTSD, cognitive theorists argue that our schemas play a significant role in how we experience trauma. People perceive the stimulus, they have beliefs about what is happening, they store the event in memory and they retrieve the memory of the experience. Cognitive psychologists believe that by understanding the role of cognitive processing during and after a trauma, we will better understand the nature of PTSD.
Young (1994) developed the early maladaptive schema model. The model states that schema formed early in life as a result of negative childhood experiences affect how we process negative life events.
Often these schema develop as a result of a lack of love in the home, abuse or deprivation. These schema then lead to feelings of guilt, "just punishment" or the inevitability of bad things happening to them. This filter is then how patients process a traumatic event that potentially leads to symptoms of PTSD.
Research in psychology: Cockram et al (2010)
To test the early maladaptive schema model, Cockram et al (2010) carried out a two-part study. The first part of the study examined the role of early maladaptive schemas in the development of PTSD in 220 Australian and New Zealand Vietnam War veterans. Veterans diagnosed with PTSD scored higher on the Young Schema Questionnaire than veterans not diagnosed with PTSD – that is, they reported more negative childhood experiences with parents and in early childhood. The results suggest that early maladaptive schemas have an important role in the development or maintenance of PTSD in Vietnam veterans. Although the focus of the research is on cognitive processes, the research also indicates that negative or stressful early life experiences may make one more vulnerable to PTSD in adulthood.
The second part of the study measured the effect of cognitive restructuring - that is, schema-based therapy aimed at changing the maladaptive schemas - on symptoms of PTSD of war veterans. Two groups were compared – PTSD patients who had schema-based therapy and those that did not. Symptoms of PTSD and anxiety improved more significantly for the schema-focused therapy group. This appears to demonstrate that schema processing plays a significant role in the disorder; however, we cannot conclude that maladaptive schema are the sole cause of the disorder.
The role of locus of control in PTSD
Cognitive therapists have also noted that PTSD patients tend to feel that they have a lack of control over their lives and that the world is unpredictable. American psychologist Julian Rotter called this feeling of autonomy a "locus of control." The theory is that individuals with an external locus of control - where they see their tragedy as beyond their control - are more likely to develop PTSD.
Bolstad and Zinbarg (1997) argue that sexual abuse in childhood results in the victim developing the expectation that life is beyond their control and that they cannot predict their future. In this study, the participants were 117 female undergraduates. The women were asked to fill in the Participant Profile Form (PPF) that collected data on childhood abuse, the PTSD symptom scale and the I-E scale which measures one’s locus of control. The findings showed that the participants who had experienced repeated or multiple cases of sexual abuse had a lower perception of control – or an external locus of control. This was also associated with greater PTSD symptoms after having been victimized as an adult.
Ratzer et al (2014) carried out a prospective study on accident victims to see if the level of locus of control would be a predictor of PTSD. In this study, fifty-two patients who were admitted to an Intensive Care Unit following a traumatic injury were followed for six months. They were given tests to measure both the level of PTSD and their locus of control. The findings showed that 19.2% of the patients developed PTSD symptoms over six months. In addition, there was a significant correlation between those with an external locus of control and the onset of these symptoms. One of the limitations of this study is that the patients are not actually diagnosed with PTSD, but the researchers relied on the results of a questionnaire. This means that there is not a reliable diagnosis of PTSD. In addition, since the study focused on the single trauma of the accident, it is possible that other traumas experienced by the individual prior to the accident may have also played a significant role in the onset of PTSD-related symptoms.
Response Styles Theory
The cognitive approach argues that patterns of thinking are responsible for our mental disorders. Nolen-Hoeksema has proposed the Response Styles Theory for both depression and anxiety-related disorders, including PTSD. This theory argues that rumination - that is, the focused attention on the symptoms of one's distress - leads to the development of PTSD and makes it difficult to treat. In the case of people living with PTSD, the focus of their rumination is often the trauma itself.
There are two components to rumination. First, the individual focuses on the symptoms of distress. Often they will say, " I just can’t concentrate on my work." They also worry about the meaning of their distress, thinking, "Will I ever get better? Has this ruined my chances for a successful career?"
Nolen-Hoeksema has found that ruminators are more uncertain about solutions they come up with to their problems than non-ruminators. This uncertainty may lead to ruminators over-interpreting everything that happens to them. Rumination contributes to feelings of hopelessness about the future and negative evaluations of one's self. Ruminators vacillate between uncertainty and hopelessness.
Research has suggested that in individuals with PTSD, rumination serves as a cognitive avoidance factor that contributes to the maintenance of symptoms by inhibiting the cognitive and emotional processing of the traumatic event, subsequently interfering with treatment engagement and outcome.
Erhing, Frank, and Ehlers (2007) carried out a longitudinal, prospective study using the Response Style Questionnaire [RSQ], developed by Nolen-Hoeksema, to examine the link between levels of rumination and PTSD symptoms in road traffic accident survivors. They found that rumination significantly predicted PTSD and depression at six months over and above what could be predicted from the initial symptom level.
Buchholz et al (2016) carried out a study of 39 women with PTSD. The women completed a clinical evaluation that included measures of PTSD symptoms, rumination, and depressive symptoms, as well as a neuroimaging session in which the participants were administered an emotion interference task. There was a significant relationship between self‐reported rumination and activity in the right orbital frontal cortex during the task. This finding suggested that women with PTSD, who had higher levels of rumination, may experience greater difficulty inhibiting negative emotional stimuli compared to women with lower levels of rumination.
Catastrophizing
One final cognitive theory of PTSD is based on the concept of catastrophizing - that is, a negative schema in which one views situations as considerably worse than they actually are.
Seligman et al (2019) examined 79,438 active-duty soldiers who had been deployed to Iraq or Afghanistan between 2009 and 2013. Soldiers highest on catastrophic thinking were 29% more likely to develop PTSD than soldiers with average catastrophic thinking, whereas soldiers lowest on catastrophic thinking were 25% less likely to develop PTSD. Additionally, soldiers higher in catastrophic thinking and experiencing higher combat intensity were 274% more likely to develop PTSD than those low on both.
Strengths
- Therapy based on cognitive restructuring is effective for many patients with PTSD.
- Cognitive theories help to explain differences in symptoms.
Limitations
- Cognitive research is highly reliant on self-reported data which is open to memory distortion and cannot always be verified for accuracy.
- The Aetiology-Treatment Fallacy argues that just because treatment may be successful, it does not mean that schema are the actual cause of the disorder.
- Cognition cannot be directly observed.
- It can be argued that cognitive arguments are an overly simplistic explanation of the disorder.
Checking for understanding
According to the cognitive approach, what role does cognition play in the origin of PTSD?
Which of the following is not one of Cockram's maladadaptive schema which may lead to PTSD?
Although Cockram argues that these schema develop as a result of childhood family experiences, he does not specify anything about the type or level of attachment between the child and the parent.
Which of the following is not a limitation of Cockram et al's (2010) study on the role of maladaptive schema on PTSD?
Ecological validity is not a problem in this study. The people studied all suffered from PTSD and were sharing about their own personal experiences. Asking them to recall childhood experiences, however, may be problematic. The fact that they have PTSD may actually be the cause, rather than the effect, of negative schema and thus could influence their perception and memory of their childhood experiences. Also, the role of stressful events in childhood cannot be discounted in this study.
Which of the following appears to be true about the role of locus of control in the development of PTSD?
One of the key limitations of Ratzer et al's (2014) study of accident victims is
Although the patients showed signs of PTSD, there was no official diagnosis.
Which of the following is a strength of cognitive arguments for the origin of PTSD?
Since data from patients is reliant on self-reporting, it is often not possible to verify the stories of their childhood experiences. As everyone processes trauma differently - and we know that memory is reconstructive - this is a problem. Even though we can see that different parts of the brain are activated when people engage in cognitive processing, psychologists do not actually know what is happening. And finally, cognitive arguments are rather reductionist, arguing that it is the way we cognitively process events that leads to PTSD. It is not a holistic approach.
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