Dual representation theory

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Visual representation of PTSD symptoms and related concepts PTSD.png
Visual representation of PTSD symptoms and related concepts

Dual representation theory (DRT) is a psychological theory of post-traumatic stress disorder (PTSD) developed by Chris Brewin, Tim Dalgleish, and Stephen Joseph in 1996. [1] This theory proposes that certain symptoms of PTSD - such as nightmares, flashbacks, and emotional disturbance - may be attributed to memory processes that occur after exposure to a traumatic event. DRT proposes the existence of two separate memory systems that run in parallel during memory formation: the verbally accessible memory system (VAM) and situationally accessible memory system (SAM). [2] The VAM system contains information that was consciously processed and thus can be voluntarily recalled or described. In contrast, the SAM system contains unconsciously processed sensory information that cannot be voluntarily recalled. [3] This theory suggests that the VAM system is impaired during a traumatic event because conscious attention is narrowly drawn to threat-related information. Therefore, memory of the trauma is heavily focused on fear, which affects information processing. This gives rise to PTSD symptoms such as trauma-related cognitions, appraisals, and emotions. The SAM system captures vivid sensory information during the traumatic event, which is automatically recalled through exposure to trauma-related triggers. This system is thought to be responsible for the presence of flashbacks and nightmares in PTSD symptomatology. [1]

Contents

Background

Prior to the development of DRT, existing theories of PTSD fell into two camps: social-cognitive theories and information-processing theories. [1] Social-cognitive theories (e.g. Horowitz's stress-response theory, [4] Janoff-Bulman's shattered assumptions theory) focused on the affected individual's assumptions about the world and the emotional and cognitive impact of the trauma on these assumptions. Information-processing theories (e.g. Foa's emotional processing theory [5] ) focus more on attentional biases to threat-related stimuli and how representation and processing of this information may generate intrusive re-experiencing symptoms of PTSD. Brewin and colleagues noted that each of the two theory camps focused on characteristics of PTSD that were distinct and may be explained by different underlying processes. They concluded that existing theories did not adequately capture the full range of PTSD symptoms. [1] They also drew from research on flashbulb memories, which suggested that a special cognitive mechanism may be involved in the encoding of highly emotionally charged memories. [6]

Clinical implications

According to DRT, the symptoms of PTSD arise when memory processes interact with other pre-trauma, peri-trauma, and post-trauma factors. Some of these factors may include severity and duration of the trauma, existing schemas about the self and the world, social support, and the presence of guilt or shame. [1] Based on these interactions, Brewin and colleagues proposed that there are three possible outcomes of post-traumatic emotional processing: completion/integration, chronic emotional processing, and premature inhibition of processing. [7]

Completion/integration

Completion/integration occurs when traumatic memories have been consciously processed and integrated with the individual’s existing memories and cognitive schemas. This outcome represents recovery from the effects of trauma exposure and minimal post-traumatic symptoms. For completion/integration to occur, there must be repeated exposure to the traumatic memory and associated stimuli to allow habituation to occur. Through habituation, the traumatized individual is increasingly able to regulate emotion when exposed to the traumatic memory. This is thought to occur as the individual is repeatedly exposed to SAMs and integrates sensory information about the trauma into conscious memory. When this occurs alongside conscious efforts to integrate the trauma with the individual’s existing schemas, successful emotional processing of the trauma is thought to occur.  DRT predicts that completion/integration would be characterized by a lack of attentional bias towards trauma-related stimuli.

Chronic emotional processing

Chronic emotional processing can occur due to severe or ongoing trauma, lack of social support, or inability to integrate the traumatic experience into existing schemas. This happens when conscious and unconscious memory processes related to the trauma are not successfully integrated. In such cases, VAMs and SAMs of the trauma may be chronically processed, which means that the person is unable to prevent the intrusion of SAMs into their consciousness. They may also have trouble shifting their existing schemas about themselves and the world. This can lead to intrusive symptoms stemming from SAMs and maladaptive preoccupation with the trauma. The person may also have attention and memory biases toward trauma-related stimuli. Moreover, according to DRT, mood symptoms such as depression and anxiety may develop as a byproduct of chronic emotional processing.

Premature inhibition of processing

Failure to integrate the trauma with existing memories and schemas may occur due to inhibited emotional processing of traumatic memory. This occurs when an individual avoids internal (e.g. thoughts, emotions, sensations) and external (e.g. people, places, situations) stimuli that activate trauma-related SAMs and VAMs. In premature inhibition, avoidance allows the individual to inhibit the intrusion of SAMs into consciousness; this hinders the integration of SAMs into the VAM system. The individual remains vulnerable to emotional distress when trauma-related stimuli are encountered. Attentional bias toward trauma-related stimuli is likely present and may be coupled with impaired memory of the trauma.

Empirical evidence

Support

Studies have examined the effect of performing visuospatial tasks during memory consolidation of distressing stimuli. These studies have found that playing the game TETRIS after exposure to distressing stimuli reduces the number of intrusive thoughts. This may mean visuospatial tasks compete with sensory processing of distressing stimuli, therefore impairing this type of processing results in fewer intrusive experiences. [8] [9] [10] Research into the human experience of natural disaster and crisis recognises that there is a large emotional component that requires addressing in order to prevent post traumatic mental health difficulties. In order to process this, an individual needs to make space to reflect on the experience and engage with the emotions connected with this experience. Through this process, growth in resilience and psychological flexibility occurs. In addition, when this process is supported collectively, increases in solidarity and community engagement are found. Conversely, when individuals do not process their emotional experiences, they are less engaged with their community, more emotionally reactive, and more likely to experience depressive symptoms. [11]

Criticism

Some studies have found that providing contextual information before exposure to distressing stimuli actually increases the frequency of intrusive thoughts. This appears to contradict DRT which posits that when contextual information (in VAM) and sensory information (in SAM) integrate, this results in decreased intrusive symptoms. [12] [13] [14] DRT has also been criticized for a lack of explanation about how the VAM and SAM systems communicate with each other. [15]

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event and can include triggers such as misophonia. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones generally with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples of distressing events include violence, rape, or a terrorist attack.

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that is a recommended treatment for post-traumatic stress disorder (PTSD), but remains controversial within the psychological community. It was devised by Francine Shapiro in 1987 and originally designed to alleviate the distress associated with traumatic memories such as PTSD.

Acute stress reaction (ASR), also known as psychological shock, mental shock, or simply shock, and acute stress disorder (ASD), is a psychological response to a terrifying, traumatic, or surprising experience. Combat stress reaction (CSR) is a similar response to the trauma of war. The reactions may include but are not limited to intrusive or dissociative symptoms, and reactivity symptoms such as avoidance or arousal. It may be exhibited for days or weeks after the traumatic event. If the condition is not correctly addressed, it may develop into post-traumatic stress disorder (PTSD).

A flashback, or involuntary recurrent memory, is a psychological phenomenon in which an individual has a sudden, usually powerful, re-experiencing of a past experience or elements of a past experience. These experiences can be frightful, happy, sad, exciting, or any number of other emotions. The term is used particularly when the memory is recalled involuntarily, especially when it is so intense that the person "relives" the experience, and is unable to fully recognize it as memory of a past experience and not something that is happening in "real time".

<span class="mw-page-title-main">Complex post-traumatic stress disorder</span> Psychological disorder

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

<span class="mw-page-title-main">Involuntary memory</span> Memory triggered by an environmental cue

Involuntary memory, also known as involuntary explicit memory, involuntary conscious memory, involuntary aware memory, madeleine moment, mind pops and most commonly, involuntary autobiographical memory, is a sub-component of memory that occurs when cues encountered in everyday life evoke recollections of the past without conscious effort. Voluntary memory, its opposite, is characterized by a deliberate effort to recall the past.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse. They may also witness abuse of a sibling or parent, or have a mentally ill parent. These events can have profound psychological, physiological, and sociological impacts leading to lasting negative effects on health and well-being. These events may include antisocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Additionally, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

Memory and trauma is the deleterious effects that physical or psychological trauma has on memory.

Cognitive processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder (PTSD) and related conditions. It includes elements of cognitive behavioral therapy (CBT) treatments, one of the most widely used evidence-based therapies. A typical 12-session run of CPT has proven effective in treating PTSD across a variety of populations, including combat veterans, sexual assault victims, and refugees. CPT can be provided in individual and group treatment formats and is considered one of the most effective treatments for PTSD.

The management of traumatic memories is important when treating mental health disorders such as post traumatic stress disorder. Traumatic memories can cause life problems even to individuals who do not meet the diagnostic criteria for a mental health disorder. They result from traumatic experiences, including natural disasters such as earthquakes and tsunamis; violent events such as kidnapping, terrorist attacks, war, domestic abuse and rape. Traumatic memories are naturally stressful in nature and emotionally overwhelm people's existing coping mechanisms.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Childbirth-related post-traumatic stress disorder is a psychological disorder that can develop in women who have recently given birth. This disorder can also affect men or partners who have observed a difficult birth. Its symptoms are not distinct from post-traumatic stress disorder (PTSD). It may also be called post-traumatic stress disorder following childbirth (PTSD-FC).

Psychological first aid (PFA) is a technique designed to reduce the occurrence of post-traumatic stress disorder. It was developed by the National Center for Post Traumatic Stress Disorder (NC-PTSD), a section of the United States Department of Veterans Affairs, in 2006. It has been endorsed and used by the International Federation of Red Cross and Red Crescent Societies, Community Emergency Response Team (CERT), the American Psychological Association (APA) and many others. It was developed in a two-day intensive collaboration, involving more than 25 disaster mental health researchers, an online survey of the first cohort that used PFA and repeated reviews of the draft.

Mental disorders can be a consequence of miscarriage or early pregnancy loss. Even though women can develop long-term psychiatric symptoms after a miscarriage, acknowledging the potential of mental illness is not usually considered. A mental illness can develop in women who have experienced one or more miscarriages after the event or even years later. Some data suggest that men and women can be affected up to 15 years after the loss. Though recognized as a public health problem, studies investigating the mental health status of women following miscarriage are still lacking. Posttraumatic stress disorder (PTSD) can develop in women who have experienced a miscarriage. Risks for developing PTSD after miscarriage include emotional pain, expressions of emotion, and low levels of social support. Even if relatively low levels of stress occur after the miscarriage, symptoms of PTSD including flashbacks, intrusive thoughts, dissociation and hyperarousal can later develop. Clinical depression also is associated with miscarriage. Past responses by clinicians have been to prescribe sedatives.

<span class="mw-page-title-main">Emily A. Holmes</span> Clinical psychologist and neuroscientist

Emily A. Holmes is a clinical psychologist and neuroscientist known for her research on mental imagery in relation to psychological treatments for post traumatic stress disorder (PTSD), bipolar disorder, and depression. Holmes is Professor at the department of Women's and Children's Health at Uppsala University. She also holds an appointment as Honorary Professor of Clinical Psychology at the University of Oxford.

<span class="mw-page-title-main">Post-traumatic stress disorder and substance use disorders</span> Association of PTSD and substance dependencies

Post-traumatic stress disorder (PTSD) can affect about 3.6% of the U.S. population each year, and 6.8% of the U.S. population over a lifetime. 8.4% of people in the U.S. are diagnosed with substance use disorders (SUD). Of those with a diagnosis of PTSD, a co-occurring, or comorbid diagnosis of a SUD is present in 20–35% of that clinical population.

In psychology, social constraints can be defined as "any social condition that causes a trauma survivor to feel unsupported, misunderstood, or otherwise alienated from their social network when they are seeking social support or attempting to express trauma-related thoughts, feelings, or concerns." Social constraints are most commonly defined as negative social interactions which make it difficult for an individual to speak about their traumatic experiences. The term is associated with the social-cognitive processing model, which is a psychological model describing ways in which individuals cope and come to terms with trauma they have experienced. Social constraints have been studied in populations of bereaved mothers, individuals diagnosed with cancer, and suicide-bereaved individuals. There is evidence of social constraints having negative effects on mental health. They have been linked to increased depressive symptoms as well as post-traumatic stress disorder symptoms in individuals who have experienced traumatic events. There seems to be a positive association between social constraints and negative cognitions related to traumatic events. Social constraints have also been linked to difficulties in coping with illness in people who have been diagnosed with terminal illness such as cancer.

Imagery Rescripting is an experiential therapeutic technique that uses imagery and imagination to intervene in traumatic memories. The process is guided by a therapist who works with the client to define ways to work with particular traumatic memories, images, or nightmares.

References

  1. 1 2 3 4 5 Brewin, Chris R.; Dalgleish, Tim; Joseph, Stephen (1996). "A dual representation theory of posttraumatic stress disorder". Psychological Review. 103 (4): 670–686. doi:10.1037/0033-295X.103.4.670. ISSN   1939-1471. PMID   8888651.
  2. ↑ Bisson, Jonathan I. (August 2009). "Psychological and social theories of post-traumatic stress disorder". Psychiatry. 8 (8): 290–292. doi:10.1016/j.mppsy.2009.05.003.
  3. ↑ Rubin, David C.; Boals, Adriel; Berntsen, Dorthe (2008). "Memory in posttraumatic stress disorder: Properties of voluntary and involuntary, traumatic and nontraumatic autobiographical memories in people with and without posttraumatic stress disorder symptoms". Journal of Experimental Psychology: General. 137 (4): 591–614. doi:10.1037/a0013165. ISSN   1939-2222. PMC   2597428 . PMID   18999355.
  4. ↑ Horowitz, Mardi J. (March 1986). "Stress-Response Syndromes: A Review of Posttraumatic and Adjustment Disorders". Psychiatric Services. 37 (3): 241–249. doi:10.1176/ps.37.3.241. ISSN   1075-2730. PMID   3957267.
  5. ↑ Foa, Edna B.; Kozak, Michael J. (1986). "Emotional processing of fear: Exposure to corrective information". Psychological Bulletin. 99 (1): 20–35. doi:10.1037/0033-2909.99.1.20. ISSN   1939-1455. PMID   2871574. S2CID   2317269.
  6. ↑ Conway, Martin A.; Anderson, Stephen J; Larsen, Steen F; Donnelly, C. M.; McDaniel, M. A.; McClelland, A. G. R.; Rawles, R. E.; Logie, R. H. (May 1994). "The formation of flashbulb memories". Memory & Cognition. 22 (3): 326–343. doi: 10.3758/BF03200860 . ISSN   0090-502X. PMID   8007835.
  7. ↑ Brewin, Chris R; Holmes, Emily A (May 2003). "Psychological theories of posttraumatic stress disorder". Clinical Psychology Review. 23 (3): 339–376. doi:10.1016/S0272-7358(03)00033-3. PMID   12729677.
  8. ↑ Holmes, Emily A.; Brewin, Chris R.; Hennessy, Richard G. (2004). "Trauma Films, Information Processing, and Intrusive Memory Development". Journal of Experimental Psychology: General. 133 (1): 3–22. doi:10.1037/0096-3445.133.1.3. ISSN   1939-2222. PMID   14979748.
  9. ↑ Holmes, Emily A.; James, Ella L.; Kilford, Emma J.; Deeprose, Catherine (2010-11-10). "Key Steps in Developing a Cognitive Vaccine against Traumatic Flashbacks: Visuospatial Tetris versus Verbal Pub Quiz". PLOS ONE. 5 (11): e13706. doi: 10.1371/journal.pone.0013706 . ISSN   1932-6203. PMC   2978094 . PMID   21085661.
  10. ↑ Holmes, Emily A.; James, Ella L.; Coode-Bate, Thomas; Deeprose, Catherine (2009-01-07). Bell, Vaughan (ed.). "Can Playing the Computer Game "Tetris" Reduce the Build-Up of Flashbacks for Trauma? A Proposal from Cognitive Science". PLOS ONE. 4 (1): e4153. doi: 10.1371/journal.pone.0004153 . ISSN   1932-6203. PMC   2607539 . PMID   19127289.
  11. ↑ Kieft, J.; Bendell, J (2021). "The responsibility of communicating difficult truths about climate influenced societal disruption and collapse: an introduction to psychological research". Institute for Leadership and Sustainability (IFLAS) Occasional Papers. 7: 1–39.
  12. ↑ Pearson, David G. (December 2012). "Contextual representations increase analogue traumatic intrusions: Evidence against a dual-representation account of peri-traumatic processing". Journal of Behavior Therapy and Experimental Psychiatry. 43 (4): 1026–1031. doi:10.1016/j.jbtep.2012.04.002. PMID   22651920.
  13. ↑ Mott, Juliette M.; Teng, Ellen J. (2015), "Evidence-Based Cognitive Behavioral Treatments for PTSD in Adults", Comprehensive Guide to Post-Traumatic Stress Disorder, Springer International Publishing, pp. 1–12, doi:10.1007/978-3-319-08613-2_17-2, ISBN   978-3-319-08613-2 , retrieved 2019-11-27
  14. ↑ Pearson, David G. (March 2014). "Are C-reps contextual representations? A reply to Brewin and Burgess". Journal of Behavior Therapy and Experimental Psychiatry. 45 (1): 220–222. doi:10.1016/j.jbtep.2013.07.010. ISSN   0005-7916. PMID   24059963.
  15. ↑ Pearson, David G.; Ross, Fiona D.C.; Webster, Victoria L. (March 2012). "The importance of context: Evidence that contextual representations increase intrusive memories". Journal of Behavior Therapy and Experimental Psychiatry. 43 (1): 573–580. doi:10.1016/j.jbtep.2011.07.009. ISSN   0005-7916. PMID   21867664.
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