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Dual representation theory of PTSD

Author: Dr Simon Moss


The dual representation theory of post traumatic stress disorder was proposed by Brewin (2001& Brewin & Joseph, 1996& for a related model, see Ehler & Clark, 2000). According to this theory, many of the features and details of some traumatic event-the sounds, smells, and sights, for example-are initially retained in a system called situationally accessible memory, somewhat akin to episodic memory. When individuals reflect upon this information consciously, attempting to understand or to integrate these features and details, the ensuing insights are retained in another system instead, called verbally accessible memory, somewhat akin to semantic memory (Semantic memory).

Sometimes, after a traumatic experience, individuals attempt to dissociate from the event. They might, for example, attempt to distract themselves from memories of this event, primarily to preclude negative mood states. Accordingly, most of the features or details of this event will be retained in situationally accessible, rather than verbally accessible, memory. Situationally accessible memory primarily represents sensory information and spatial images. Because this information is not integrated or understood, the temporary sequence is not represented.

Cues or stimuli in the environment that are associated with this traumatic event will tend to activate or prime the contents of this memory system. Individuals will thus experience intrusive images and flashbacks-hallmarks of PTSD. Accordingly, dissociation immediately after some traumatic event should predict subsequent PTSD.

Empirical evidence

Retrospective studies

A variety of studies have confirmed this proposition. A meta-analysis, for example, conducted by Ozer, Best, Lipsey, and Weiss (2003), showed that dissociation shortly after the traumatic event-called peritraumatic dissociation-was highly related to subsequent PTSD. Factors before or months after the traumatic episode were not as predictive of PTSD.

Nevertheless, many of these studies are retrospective. That is, participants are asked to recall the extent to which they exhibited dissociation, such as numbing or detachment, months or even years earlier. Unfortunately, these recollections are often unstable over time. Indeed, when PTSD symptoms diminish, recollections of previous dissociation also tend to change (e.g., Marshall & Schell, 2002). Hence, the results of these retrospective studies are tenuous.

Laboratory studies

Prospective studies are sometimes conducted to examine the association between peritraumatic dissociation and subsequent PTSD (Candel & Merckelbach, 2004). Nevertheless, to establish causality more definitely, experimental studies should be conducted. That is, dissociation after some mildly traumatic event, such as exposure to a distressing documentary, should be induced. Indeed, several studies have induced forms of dissociation (e.g., Hagenaars, van Minnen, Holmes, Brewin, & Hoogduin, 2009& Holmes, Brewin, & Hennessy, 2004& Holmes, Oakley, Stuart, & Brewin, 2006).

Some, but not all, of these studies have shown that dissociation after some mildly traumatic event does not predict subsequent symptoms. In the study conducted by Holmes, Brewin, and Hennessy (2004), some of the participants, while watching a distressing movie, were instructed to stare at a dot-to induce dissociation. Relative to controls, these participants were no more likely to experience intrusions over the next week.

Similarly, in a study conducted by Holmes, Oakley, Stuart, and Brewin (2006), participants again watched a disturbing movie. Dissociation was induced through hypnosis. Again, relative to controls, dissociation did not evoke more intrusions in the future.

Nevertheless, according to Hagenaars, van Minnen, Holmes, Brewin, and Hoogduin (2009), these findings do not definitely show that dissociation is unrelated to subsequent symptoms of PTSD. Specifically, distinct forms of dissociation have been differentiated. A subset of these facets might alleviate PTSD. Some researchers distinguish somatoform dissociation, which entails analgesia, freezing of the body, and other forms of detachment from bodily experiences, from psychological dissociation, which entails disruption to memory or concentration, for example (Maaranen, Tanskanen, Haatainen, Honkalampi, Koivumaa-Hankanen, Hintikka, et al., 2005).

Hagenaars, van Minnen, Holmes, Brewin, and Hoogduin (2009) conducted a study to examine the effects of somatoform dissociation on subsequent intrusions. Participants watched a movie, which spanned 10 minutes, and depicted the aftermath of a road accident, including dead bodies and injured victims. Participants were assigned to three conditions. In the control condition, participants were free to sit and move naturally during the movie. Second, some participants were instructed to sit as still as possible. Third, the remaining participants induced catalepsy through hypnosis. Their arms were induced into a catalepetic state by moving the forearm up and down slowly. The upper body was induced into a catalepetic state by moving the shoulders forwards and backwards. The feet were placed under the knees (for a validation of this technique, see Hagenaars, Roelofs, Hoogduin, & Van Minnen, 2006).

Relative to controls, participants who did not move while watching the movie-either through instructions or hypnosis-reported more intrusive thoughts over the next seven days. The frequency of intrusive thoughts was assessed by instructing participants to maintain a diary of these thoughts as well as recording the content of these intrusions.

According to Hagenaars, van Minnen, Holmes, Brewin, and Hoogduin (2009), limited movement resembles freezing-which evolved in response to danger (cf., Nijenhuis, Spinhoven, Vanderlinden, Van Dyck, & Van der Hart, 1998). This defensive state might preclude the processing of information, to ensure that attention is oriented towards possible threats and hazards.

Writing about traumas: Expressive writing

Many studies have shown that writing about previous traumas tends to improve wellbeing. These studies are sometimes conceptualized as support for dual representation theory.

In a typical study, some participants write about a traumatic or stressful experience for approximately 15 minutes, over three or so consecutive days (e.g., Pennebaker & Beall, 1986). Other participants write about a relatively trivial topic instead, such as their plan for the day. Writing about traumatic topics typically amplifies negative emotional states initially but, after several days, tends to improve wellbeing.

These benefits have been demonstrated in college students (Booth, Petrie, & Pennebaker, 1997& Pennebaker, Colder, & Sharp, 1990& Pennebaker, Kiecolt-Glaser, & Glaser, 1988& Petrie, Booth, Pennebaker, Davison, & Thomas, 1995) as well as homeless persons (de Vicente, Munoz, Perez-Santos, & Santos-Olmo, 2004), men with prostrate cancer (Rosenberg, Rosenberg, Ernstoff, Wolford, Amdur, Elshamy, et al., 2002), and patients with rheumatoid arthritis or asthma (Smyth, Stone, Hurewitz, & Kaell, 1999). Nevertheless, this protocol has not been as effective in patients with PTSD (Gidron, Duncan, Lazar, Biderman, Tandeter, & Shvartzman, 2002., 2002) or women with histories of child sexual abuse (Batten, Follette, Rasmussen Hall, & Palm, 2002). Thus, variations to the protocol might be warranted if cognitive processing is especially disturbed (Sloan & Marx, 2004). Indeed, the benefits seem to be more pronounced when the participants are relatively healthy rather than experiencing clinical disturbances (see Smyth, 1998).

The benefits of writing have been ascribed to models that resemble dual representation theory. According to these accounts, the writing process enables individuals to ensure the features and details of a traumatic episode can be organized and integrated coherently. The event can be understood and processed, which diminishes the sensory and emotional intensity of isolated memories (e.g., Pennebaker & Seagal, 1999& Smyth, True, & Souto, 2001). This account implies that writing shifts some of the contexts of situationally accessible memory to verbally accessible memory.

Consistent with this premise, over the three sessions, individuals increase the use of words that represent cognitive processing-words relate to cause or insight. Words that relate to emotions tends to diminish (Pennebaker, 1993& Pennebaker & Francis, 1996). Nevertheless, this shift was not observed in participants who were experiencing symptoms of trauma (Batten, Follette, Rasmussen Hall, & Palm, 2002).

Alternative accounts of these benefits of writing have been formulated. Although still consistent with dual representation theory, Pennebaker (1989) argued that individuals often strive to inhibit traumatic memories, which merely amplify these emotions or images. Writing overcomes this tendency to inhibit these memories. Nevertheless, some findings challenge this perspective. Even writing about traumas that have been disclosed, rather than inhibited, did seem to improve wellbeing (Greenberg & Stone, 1992& Greenberg, Wortman, & Stone, 1996). Alternatively, writing might simply increase exposure to emotional material. The emotions might, over time, dissipate because of habituation (Sloan & Marx, 2004).

Other effects of writing about traumas

Kellogg, Mertz, and Morgan (2010) showed that writing about traumatic events may increase working memory capacity, without necessarily diminishing the frequency of intrusive thoughts (see Klein & Boals, 2001, for a related finding). In their study, some participants wrote about a traumatic or negative event three times, over the course of eight days. Other participants, assigned to a control condition, instead wrote about time management.

Both before and after this writing task, the working memory of individuals was assessed. In particular, participants completed the arithmetic operation word span memory task. That is, a sequence of mathematical equations was presented, which participants were instructed to solve. Beside each equation was a letter. Participants were told to memorize up to seven of these letters at a time. Successful performance on this task implies that working memory capacity is extensive.

Furthermore, participants completed the impact of event scale--intended to ascertain the extent to which they experienced intrusive thoughts and attempted to avoid cognitions about this event. In addition, they reported the frequency with which they experienced various symptoms of illness, such as chest pain, before and after the writing task.

Working memory span improved over time, especially in participants who wrote about the traumatic event. Improvement in working memory was especially pronounced in participants who referred to causal terms, like "because", or insight, like "realize" during the writing task. Nevertheless, the frequency of intrusive thoughts was unaffected by this writing intervention (Kellogg, Mertz, & Morgan, 2010). Finally, the frequency of intrusive thoughts and avoidance of cognitions was positively correlated, but only in the control condition.

According to Kellogg, Mertz, and Morgan (2010), the writing task may curb the emotional impact, rather than frequency, of intrusive thoughts. After writing about a traumatic event, intrusive thoughts are not as intense, and hence working memory is not distracted. Thus, individuals do not feel the need to avoid these memories, which explains the diminished correlation between the frequency of intrusive thoughts and the avoidance of cognitions in this condition.

Factors that amplify or inhibit the effects of writing about traumas

The benefits of these writing tasks also depends on the timing of these endeavors. In most studies, participants write about a traumatic event on three separate days, each session lasting about 30 minutes. The benefits of these sessions are more pronounced when distributed over a longer period of time--a month rather than a week, for example (see Smyth, 1998).

North, Pai, Hixon, and Holahan (2011) recommended and then validated a novel writing exercise that blends acceptance of negative emotions (cf., ACT therapy) with positive reappraisal (see emotional regulation). In particular, after a trauma, individuals are first asked to write for 40 minutes, spread across two days, about their negative emotions, reminiscent of acceptance. Then, individuals are asked to write for 40 minutes, spread across two days, about the positive implications of this incident.

This exercise offers the benefits of both acceptance and positive reappraisal. Specifically, when negative emotions are accepted, unpleasant thoughts and feelings are not as likely to be suppressed. Therefore, they are not as likely to rebound later (see ironic rebound). In addition, when positive reappraisal is applied, individuals are able to convert these negative emotions to positive thoughts. That is, negative emotions will elicit favorable cognitions in the future, increasing wellbeing.

To validate this exercise, North, Pai, Hixon, and Holahan (2011) conducted a study in which undergraduate students reflected upon the main challenge in their lives. Some individuals were asked merely to write about the trauma for 20 minutes each day, across four days. Other individuals were asked to consider only the positive implications or facets for four days. Finally, some individuals were asked to write about the negative emotions for two days and the positive implications for two days. This exercise that blended acceptance of negative emotions with positive reappraisal was more likely to promote feelings of happiness than were the other exercises.

Related findings

Changes to reactivated memories

Past memories, after they are strongly reactivated or retrieved, can be changed. Traumatic memories, for example, could potentially be transformed into more pleasant memories.

This possibility was explored by St. Jacques and Schacter (2013) in a complex, but interesting, study. In this study, participants toured a museum. The tour comprised many events, such as an exhibition of dinosaurs. Each event included 6 stops, such as stopping behind a computer or display case. Every 15 seconds, a camera, attached to participants, photographed the scene.

Two days later, participants completed a computer task. On each trial, a photograph of the six stops of one event sequentially appeared on the screen. On some trials, the order of these photographs matched the order in which participants experienced these stops& because of this congruence, the event should be strongly reactivated. On other trials, the order of these photographs diverged from the order in which participants experienced these stops& because of this incongruence, the event should not be strongly reactivated. Half a second later, another photograph of this event, but at a stop the participants had not experienced, appeared--called the novel stop. To focus their attention, participants were asked to indicate whether the stop is related to this event.

Finally, two days later, participants completed a recognition task. Pairs of photos, such as two stops associated with one event, were presented. The task of participants was to decide whether they had observed these stops during the tour. If the event had been strongly reactivated, individuals often assumed incorrectly they had experienced the novel stop& and they more accurately recognized the stops they had experienced. If the event had not been strongly reactivated, this problem declined. Accordingly, as this study shows, memories that are strongly reactivated, because the retrieval cues are congruent with the event, are more susceptible to distortion or change.

Expressive art

Some researchers have extended the notion of expressive writing to art. For example, according to Henderson, Rosen, and Mascaro (2007), some people may prefer to express their traumas or emotions in art rather than in words. Art, rather than writing, may generate the same benefits, organizing traumatic memories into a cohesive narrative.

In one study, for example, conducted by Henderson, Rosen, and Mascaro (2007), the participants were individuals who had experienced moderate traumas, such as bereavement, serious health concerns, or victims of violence. In the experimental group, participants were asked to draw mandalas, representing the emotions they associate with the trauma, for 20 minutes on 3 consecutive days. Mandalas are circular, ornate patterns, traditionally surrounding a square. In the control group, participants drew a specific object. Participants completed measures of trauma, depression, anxiety, and meaning before and after this intervention as well as a month later.

Drawing mandalas that reflect their emotions was more likely than drawing a specific object to diminish trauma a month later. During interviews, participants indicated they felt the drawings enabled them to express feelings they had withheld.

Psychological first aid

Psychological first aid, as outlined by Ruzek, Brymer, Jacobs, Layne, Vernberg, and Watson (2007), entail a series of stages that practitioners often apply immediately to victims of some traumatic event. Ruzek, Brymer, Jacobs, Layne, Vernberg, and Watson (2007) showed that each of these stages have been shown to be helpful immediately after crises.

During the first stage, called contact and engagement, the practitioner attempts to contact victims, including individuals who may not initially seek assistance. During the second stage however, called psychological safety, the practitioner attempts to cultivate immediate psychological safety. They highlight the victim is now safe and support will be provided to manage the situation. During the third stage, this safety is buttressed with stress management techniques, intended to facilitate a feeling of calmness.

Then, practitioners attempt the fourth stage, called empowerment of the survivor, in which they inspire the victims to consider some reasonable goals they may pursue in the near future. These goals are intended to instil a sense of power, control, and agency. Fifth, the practitioner attempts to mobilize social support, partly by referring the victim to relevant experts and communities, as well as by asking questions about relevant friends or family. Sixth, the practitioner attempts to cultivate hope in the victim, focussing on inspiring possibilities and aspirations. Finally, the practitioner may refer the victim to suitable medical services, child protection services, legal aid, accommodation services, and psychiatric services.

Critical Incident Stress Debriefing

Critical incident stress debriefing was promulgated by Mitchell (1983) and was, largely, developed to diminish the effect of traumatic events on the lives of emergency service personnel (see also Everly & Mitchell, 1995). Although many individuals are exposed to traumatic events, emergency service personnel are especially likely to experience these events as well as suffer PTSD, partly because they feel they should be able to withstand such occurrences. Critical incident stress debriefing is intended to prevent PTSD. In addition, the procedure is intended to identify individuals who are susceptible to other psychological problems and, therefore, should be referred to other health services.

Critical incident stress debriefing is one phase of a broader approach called critical incident stress management. Broadly, critical incident stress management enables individuals to discuss a traumatic incident, without judgment or criticism, to a peer or mental health worker. The first phase is called defusing, initiated immediately after the incident, preferably before the person has retired to bed. This phase is conducted informally, often near the scene of a traumatic event, and is designed to prevent harm as a consequence of an escalation of emotions and injurious behavior. This phase is usually restricted to victims of some event rather than emergency service personnel. During this phase, the practitioner:

The second phase is called debriefing and is usually undertake within 3 days of the incident. During this phase, individuals or teams are granted opportunities to discuss their experience. In particular, these individuals consider the effect of this incident on their emotions, thoughts, and lives--as well as contemplate possible strategies and behaviors to cope with these effects. The practitioner also identifies people who may be vulnerable to psychological problems referring these individuals to suitable health practitioners as well as other relevant services. Typically, later in the day, the practitioner will contact the individuals, to assess their emotions and safety. The process tends to entail seven steps, initiated with individuals separately or in team contexts (Everly & Mitchell, 1995):

The aim of this process is to enable individuals to consider their thoughts, and then their emotions, in a setting that is safe, sensitive, and rational. The verbalization enables individuals to translate emotional memories into more objective responses. After this phase, the practitioner monitors their progress over a week or so, attuned to individuals who may need additional support

The efficacy of this debriefing has received mixed support. A meta-analysis, conducted by Litz, Gray, Bryant, and Adler (2002), showed that critical incident stress debriefing does not significantly reduce the incidence of PTSD. Indeed, some studies show that debriefing, at least in some settings such as victims of fires or motor vehicle accidents, can increase the incidence of PTSD (for a review, see Paterson, Whittle, & Kemp, 2014 ). Arguably, critical incident stress debriefing may increase the salience of traumatic episodes, increasing the likelihood of rumination rather than reflection. These memories are attached to stronger emotions, increasing their salience and effect on other memories.

To explore the source of these complications, Paterson, Whittle, and Kemp (2014) conducted a laboratory study, in which they explored the effects of two phases of critical incident stress debriefing: reaction and facts. In particular, pairs of participants watched a disturbing video of an autopsy& actually, each member was exposed to a slightly different variant of each video. Next, participants were assigned to one of three conditions. In one condition, they discussed their emotional reaction to these videos, similar to the reaction phase. In the second condition, they discussed only the facts about the video, similar to the facts phase. In the final or control condition, participants merely wrote about their previous weekend. Finally, they completed measures that gauge anxiety, avoidance (e.g., "I tried not to think about it"), and intrusions (e.g., "I had waves of strong feelings about it"). Finally, their memory of this video was assessed.

As hypothesized, if participants discussed the emotions this video evoked, they were more likely to experience intrusions afterwards. This re-experiencing of emotions seemed to increase the likelihood of intrusions and rumination. In addition, if participants discussed the facts or details of this video, their memory was more likely to be distorted, because each individual had been exposed to different variants. Accordingly, two phases of critical incident stress debriefing, facts and emotions, may elicit some complications.

Despite these complications, research indicates that group critical incident stress debriefing may be more effective, as Tuckey and Scott (2014) demonstrated. In this study, groups of emergency workers, all of whom had been exposed to the same traumatic fire, received either critical incident stress debriefing, education about stress management, or no treatment. Critical incident stress debriefing was more likely than education to diminish alcohol intake after the incident. In addition, critical incident stress debriefing was more likely than no treatment to improve quality of life.


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