Posttraumatic Stress Disorder 515
vertently lead to an increase in intrusion frequency and associated distress. Likewise, in
the current cognitive model (see Figure 12.1), the negative appraisal of trauma- related
intrusions will lead to a variety of control efforts that might reduce reexperiencing
symptoms and emotional arousal, but in the long term they contribute to the persistence
of PTSD.
Cognitive Control and Suppression Efforts
The activation of maladaptive posttrauma schemas, the dominance of threat- biased
information processing, the repeated occurrence of intrusive recollections, and the nega-
tive appraisal of these trauma- related intrusions will cause the individual with PTSD to
be strongly motivated to immediately terminate the intrusions and reduce their associ-
ated distress. A variety of cognitive and behavioral strategies will be employed that lead
to quick relief of PTSD symptoms even though they contribute to the persistence of the
disorder over the longer term. Ehlers and Clark (2000) note that maladaptive control
strategies contribute to the maintenance of PTSD by directly producing symptoms, pre-
venting change in the negative appraisals of the trauma, and preventing change in the
trauma memory itself.
Thought suppression is a common maladaptive coping strategy found in PTSD. In
his review Rassin (2005) concluded that trying not to think about a trauma can lead to
the same paradoxical increase in the frequency of trauma- related intrusions as seen in
the suppression of more neutral thoughts like white bears. However, it is unclear what
effects suppression may have on the quality of the recollection. Furthermore, active
attempts to dismiss an intrusive image of the trauma, for example, may increase its
salience by confirming the individual’s misinterpretation of threat. Failure to effectively
gain control over the intrusion would confirm the individual’s belief that these trauma-
related thoughts or images really are a threat to personal well-being that will lead to
long-term negative consequences (i.e., Ehlers & Steil, 1995; Ehlers & Clark, 2000).
Other untoward effects of thought suppression might be an increase in the individual’s
level of distress as well as cognitive load, which would make it harder to concentrate
on daily tasks and activities. Thus attempts to suppress trauma- related intrusions might
paradoxically increase the extent of their interference in daily functioning, which would
reinforce the patient’s belief that PTSD symptoms are having significant and enduring
negative consequences.
Two other response strategies associated with trauma- related intrusions are rumi-
nation and dissociation (Ehlers & Clark, 2000). Rumination is a persistent, recyclic,
and passive form of thinking about the trauma and its consequences that leaves indi-
viduals with PTSD stuck in their current emotional state (i.e., Ehlers & Clark, 2000;
Papageorgiou & Wells, 2004). Ehlers and Clark suggested that rumination is a cogni-
tive avoidance strategy that strengthens negative appraisals of the trauma and might
interfere with the formation of more complete trauma memories. Dissociative symptoms
such as derealization, depersonalization, and emotional numbing may be automatic or
deliberate cognitive coping strategies intended to avoid awareness of distressing recol-
lections of the trauma or to suppress hyperarousal symptoms (Taylor, 2006). Ehlers and
Clark (2000) suggested that dissociative symptoms might impede elaboration of the
trauma memory and its integration with other autobiographical memories.