What is Ehlers and Clark PTSD formulation?

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This blog post will explore Ehlers and Clark’s PTSD formulation or the Cognitive model of PTSD by Ehlers and Clark.

We will also briefly discuss what is PTSD, what are the criteria for the diagnosis of PTSD and what does Ehlers and Clark suggest for the treatment of PTSD.

What is Ehlers and Clark PTSD formulation?

Ehlers and Clark’s model of PTSD is a cognitive behavioural model of PTSD that explains why some people do not recover after trauma. 

According to this model, chronic PTSD develops when trauma survivors cognitively process the traumatic event as something that is a current serious threat- meaning that the past traumatic event is still a very real and very present threat to their survival, well being etc. 

According to this model, this perceived current threat has two sources:

  • Negative personal meanings given to the traumatic event
  • Disjointed Memory of the trauma

The negative personal meanings or the appraisals that one develops after a traumatic event is usually about one’s self as in “I am incapable of protecting myself” or about the world and other people such as “people cannot be trusted” “The world is unsafe”.

Another cause of this chronic PTSD is that the memory of the trauma is disjoint or elaborated poorly which is easily triggered. The memories also do not need context and often have the same threatening meanings as the original experience of the trauma. 

It is assumed that the disjointed memories and the Negative appraisals have a reciprocal memory according to this model and it is what develops that sense of urgency related to a perceived current threat.

The model also proposes that the sense of current threat is what motivates various behaviours that are meant to reduce the feelings of threat but instead it maintains the symptoms such as rumination, numbing, denial, suppression, avoidance etc.

Thus, the core hypothesis of Ehlers and Clark’s model is that personal meanings or appraisals that are negatively related to the trauma, disjointed memories, and unhelpful/ unadaptive behavioural strategies to reduce the sense of current threat maintains PTSD.

Ehlers and Clark’s model further hypothesised that how one cognitively processes the trauma is what predicts the onset and development of PTSD because this cognitive process is what influences the negative appraisals of the trauma and the memory as well. 

These cognitive processes that are unhelpful include four types:

  • Data-driven processing where the individual processing of the event involves one preferring certain information over the other regarding the trauma which leads to disjointedness in the memories related to the trauma, 
  • Lack of self-referential processing where there is an inability, within the individual, to understand that the traumatic event is part of their autobiographical experiences of their life demanding that they think that this event is the end of all possibilities and future.
  • Mental defeat where an individual has lost all and utter hope in their autonomy, their individuality, capabilities, and abilities to cope with the trauma and this loss is perceived and internalised by them- leading to negative appraisal of themselves. 
  • Dissociation where the individual feels like they are not part of the trauma which can further cause disjointedness in their memories. 

What does the Ehlers and Clark model suggest for treating PTSD?

The Cognitive therapy for PTSD is informed by the Ehlers and Clark model of PTSD and cognitive behavioural therapy (CBT). 

According to the treatment suggestions for PTSD, treatment should involve the following:

Identify relevant evaluations, thoughts, beliefs, and memories of the traumatic event.

Help clients understand the meaning behind these events and the traumatic memories.

Help them identify who they presently appraise them and recognize the pessimistic evaluations of the trauma and help them understand how this can exaggerate current feelings of threat, 

The therapist can use various strategies of exploration such as the Socratic questioning to help the patient arrive at the evaluations they have made and guide them towards new evaluations.

Modifying pessimistic evaluations of the world, themslebes, and others as well the memories of trauma that interpret a person’s way of life.

This can be done by helping the client write, think about, and relief about the new evalitions while also thinking or considering the traumatic memory to imbed the new eeveelutions into the memory they relive.  

A meaningful narrative must also be established where it accounts the client;s life before trauma and ends after the client feels secure and safe. This can be done by writing a comprehensive account of the trauma, visiting the location, etc all the while the client is set firm in the new evaluation they have modified.

Finally, the therapist can help clients stop behaviours, and other ways of thinking that can sustain PTSD symptoms in the long run such as rumination, safety seeking behaviours, and suppression. 

These are discussed in sessions and behavioural and cognitive strategies are developed to disrupt these behaviours and thought patterns.

Weekly sessions over three months either individually or in groups. 

Finally, the therapist helps the patient stop behaviours and ways of thinking that may decrease the feeling of current threat but in the long-term actually sustain PTSD symptoms. The therapist and patient target such things as rumination, safety-seeking behaviours, and thought suppression. They talk about how these behavioural and cognitive strategies disrupt everyday behaviour and potentially contribute to keeping the PTSD symptoms. The patient is encouraged to drop these unhelpful strategies or to try behavioural experiments to overcome or reverse their impact.

What is PTSD?

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event. It could be a direct or indirect experience and can even happen due to repeated exposure to details of a traumatic event.

People with PTSD often struggle with their cognitions and emotions because they relive the event through flashbacks and nightmares, as well as uncontrollable thoughts about the event. 

People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong reactions to ordinary events and often feel detached and isolated. 

PTSD is a debilitating disorder that can impact a person’s relationships, work, responsibilities like parenting and occupational/ academic tasks and can severely impact their sense of self. 

What are the diagnostic criteria of PTSD?

The following diagnostic criteria has been taken from the DSM-5 published by the American psychological association in 2013.

The criteria listed below apply to people above the age of 6 where for children below the age of six, the criteria is slightly different.

For PTSD to be diaognosed, the individual should have had Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

  • Directly experiencing the traumatic event(s).
  • Witnessing the event(s) as it occurred to others in person.
  • Learning that the traumatic event(s) occurred to a close family member or close friend. 
  • Experiencing repeated or extreme exposure to details of the traumatic event(s) 

There is also the experience of intrusive thoughts beginning after the traumatic event(s) occurred such as:

  • Recurrent distressing memories of the traumatic event(s). 
  • Recurrent distressing dreams in which the content is related to the traumatic event(s). 

They also experience dissociative reactions such as flashbacks, where the individual feels or acts as if the traumatic event(s) were recurring. 

They also experience psychological distress that is intense when exposed to internal or external cues that resemble an aspect of the traumatic event along with physiological reactions such as sweating, higher heart rate, shivering etc.

There is persistent avoidance of stimuli associated with the traumatic event(s) such as:

  • Avoiding distressing memories, thoughts, and feelings, of the traumatic events. 
  • Avoidance of external reminders (people, places, conversations, activities, objects, situations) of the traumatic event(s).

The struggle with altering cognitive processes and moods after the traumatic event has occurred such as:

  • Inability to remember an important aspect of the traumatic event(s).
  • They develop extremely negative beliefs or expectations about oneself, others, or the world
  • They have distorted ideas about the consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
  • They are in a perpetual negative state of mood such as anger, sadness, etc. 
  • Feelings of detachment or estrangement from others- loneliness.
  • Inability to experience positive emotions such as love, happiness. 

They may also exhibit the following affective symptoms such as:

  • Irritable behaviour and angry outbursts (with little or no provocation), typically expressed as aggression. 
  • Reckless or self-destructive behaviour.
  • Hypervigilance.
  • Exaggerated startle response.
  • Problems with concentration.
  • Sleep disturbance 

These symptoms must persist for more than one month and cause significant distress and impairment in their social, and occupational functioning and are not attributed to other disorders, medical conditions, and substance use.

Conclusion

This blog post has explored Ehlers and Clark’s PTSD formulation or the Cognitive model of PTSD by Ehlers and Clark.

We have also briefly discussed what is PTSD, what are the criteria for the diagnosis of PTSD and what does Ehlers and Clark suggest for the treatment of PTSD.

FAQ related to Ehlers and Clark PTSD formulations

What is the cognitive model of PTSD?

Cognitive therapy for PTSD suggests that a person will develop PTSD if the person processes a traumatic event in a way that leads them to believe that the threat is still present and still severe.

What are the 5 stages of PTSD?

The five stages of PTSD include:

  • Impact or Emergency Stage
  • Denial/ Numbing Stage.
  • Rescue Stage where treatment and intervention begins.
  • Short-term Recovery or Intermediate Stage.
  • Long-term reconstruction or recovery stage.

Why was PTSD removed from anxiety disorders?

PTSD’s recategorization and removal from anxiety disorders is that PTSD often manifests with non-anxiety symptoms such as dissociative experiences, anger outbursts, and self-destructive behaviour.

What is hyperarousal in PTSD?

Hyperarousal is a severe symptom of PTSD where one’s fight-or-flight response is perpetually turned on, and the individual lives in a state of constant tension making them susceptible to panic at the slightest trigger or change. 

References

American Psychological Association. (2017). Post Traumatic stress disorder Cognitive Therapy (CT). Retrieved on 31st December 2021. https://www.apa.org/ptsd-guideline/treatments/cognitive-therapy

Beierl, E., Böllinghaus, I., Clark, D., Glucksman, E., & Ehlers, A. (2020). Cognitive paths from trauma to posttraumatic stress disorder: A prospective study of Ehlers and Clark’s model in survivors of assaults or road traffic collisions. Psychological Medicine, 50(13), 2172-2181. doi:10.1017/S0033291719002253

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.

Ehlers, A., & Clark, D. M. (2008). Post-traumatic stress disorder: the development of effective psychological treatments. Nordic journal of psychiatry, 62 Suppl 47(Suppl 47), 11–18. https://doi.org/10.1080/08039480802315608

American psychiatric Association (2020). What Is Posttraumatic Stress Disorder? Retrieved on 31st December 2021. https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

Centre for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioural Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Exhibit 1.3-4, DSM-5 Diagnostic Criteria for PTSD. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part1_ch3.box16

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