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Cognitive Approaches to Posttraumatic Stress

Disorder: The Evolution of
Multirepresentational Theorizing
ARTICLE in PSYCHOLOGICAL BULLETIN APRIL 2004
Impact Factor: 14.76 DOI: 10.1037/0033-2909.130.2.228 Source: PubMed

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Psychological Bulletin
2004, Vol. 130, No. 2, 228 260

Copyright 2004 by the American Psychological Association, Inc.

0033-2909/04/$12.00 DOI: 10.1037/0033-2909.130.2.228

Cognitive Approaches to Posttraumatic Stress Disorder: The Evolution of

Multirepresentational Theorizing
Tim Dalgleish

Medical Research Council Cognition and Brain Sciences Unit

The evolution of multirepresentational cognitive theorizing in psychopathology is illustrated by detailed
discussion and analysis of a number of prototypical models of posttraumatic stress disorder (PTSD).
Network and schema theories, which focus on a single, explicit aspect/format of mental representation,
are compared with theories that focus on 2 or more explicit representational elements. The author argues
that the latter theories provide a more complete account of PTSD data, though are not without their
problems. Specifically, it is proposed that at least 3 separate representational elementsassociative
networks, verbal/propositional representations, and schemasare required to generate a comprehensive
cognitive theory of PTSD. The argument that the development of multirepresentational cognitive theory
in PTSD is a paradigm case for the development of similar theories in other forms of psychopathology
is elaborated, and a brief agenda is proposed promoting 2 levels of theorizing deep, formal theory
alongside more localized, applied theory.

jury is still out as to whether the evolution of multirepresentational

theorizing in psychopathology is either necessary or a good thing.
The aims of this review are, first, to evaluate the pros and cons
of different types of mental representational construct in the cognitive modeling of psychopathological states and, second, to examine the evolutionary development toward multirepresentational
cognitive theorizing in psychopathology and to assess the advantages and disadvantages of such an approach. To achieve these
aims the review focuses on detailed analysis of a number of
cognitive approaches to posttraumatic stress disorder (PTSD). The
reason for focusing on PTSD and not some other condition is that,
in seeking to account for the disorder, theorists have used a wide
range of mental representations and processes and have proposed
both multirepresentational and unirepresentational theories. For
example, PTSD has been as persuasively modeled with associative
networks (e.g., Foa, Steketee, & Rothbaum, 1989) as it has by
theorists drawing on the concept of schemas (e.g., Horowitz, 1997;
Janoff-Bulman, 1985). This theoretical diversity means that the
advantages and disadvantages of different types of mental representations and of unirepresentational approaches over multirepresentational approaches can be more readily assessed with respect
to the same database. There is a danger of course that what holds
for PTSD has little or no generalizability to other forms of psychopathology. However, there are good reasons to believe that this
is not the case, and this issue is discussed at the end of the article.
I therefore seek in this review to evaluate cognitive theories of
PTSD in two main ways. First, how effective the theories are at
accounting for what one might call the core data of the disorder.
Second, how good the theories are as theories. In other words, how
adequately any given type of mental representation or combination
of mental representations has been conceptualized in the context of
the core data. To this end, a number of yardsticks for theories as
theories evaluation are developed. A final agenda of the review is
to illustrate how the representational complexity in cognitive theories of PTSD has evolved from one theory to another and to

A key feature of the cognitive approach to understanding psychopathology is the idea that information is represented in the
mind in different ways. Cognitive theories of psychopathology
historically have embraced various forms of mental representation
(e.g., schemas, propositional representations, pictorial or image
representations, distributed networks). This is because each type of
mental representation is seen to have strengths and weaknesses
with respect to its utility in modeling psychopathological states.
More recently, cognitive theorizing in psychopathology has been
characterized by a plethora of so-called multirepresentational theories (e.g., Brewin, 1989; Power & Dalgleish, 1997; Teasdale &
Barnard, 1993; Wells & Matthews, 1994; see also Teasdale,
1999b, for a review). Such theories combine more than one format of mental representation in pursuit of greater explanatory
powera necessary aspiration in the face of an ever-expanding
database on psychopathology. The majority of these multirepresentational approaches have evolved out of simpler unirepresentational approaches such as Horowitzs work using schematic
representations (e.g., Horowitz, 1986) or Bowers (1981) associative network model of affect and cognition. As with any given type
of mental representation considered alone, the multirepresentational approach itself has strengths and weaknesses. For example,
multirepresentational approaches do seem to buy the theorist increased explanatory power. However, the resulting models are
more complex and difficult to understand. For these reasons, the

I thank the following people for helpful discussions about PTSD theory
over the years: Chris Brewin, David Clark, Anke Ehlers, Edna Foa, Mick
Power, and Richard McNally. Thanks also to Phil Barnard, John Teasdale,
and Jenny Yiend for comments on an earlier version of this article.
Correspondence concerning this article should be addressed to Tim
Dalgleish, Emotion Research Group, Medical Research Council Cognition
and Brain Sciences Unit, 15 Chaucer Road, Cambridge CB2 2EF, England.
E-mail: tim.dalgleish@mrc-cbu.cam.ac.uk

228

COGNITIVE MODELS OF PTSD

discuss the advantages and disadvantages conveyed by this

evolution.
This article is structured as follows. First, what one might think
of as the core data of PTSD that any theory should seek to explain
are very briefly outlined (cf. Brewin, Dalgleish, & Joseph, 1996;
Jones & Barlow, 1990). Second, a set of evaluative criteria for the
theories as theories is presented. Third, the selected theories of
PTSD are presented and discussed. Finally, a General Discussion
section seeks to evaluate the utility of multirepresentational theorizing with respect to PTSD and to examine the extent to which
this can be thought of as a paradigm case as regards other forms of
psychopathology. A tentative agenda for future cognitive theorizing in psychopathology is also outlined.

The Core Data of PTSD

The PILOTS database (an electronic index to the worldwide
literature on PTSD and other mental health consequences of exposure to traumatic events, produced by the U.S. National Center
for PTSD in Boston; available at http://www.ncptsd.org/publications/pilots/) comprised 22,323 references as of August 2002.
Notwithstanding the fact that only a subset of these publications
will contain data that a theorist need be concerned with, it remains
the case that it is not possible for any reviewer to evaluate a set of
theories with respect to all (or even a majority of) the individual
studies in this area in any meaningful way. One solution is therefore to use review articles, meta-analyses, and prototypical and
gold standard empirical studies as the basis for distilling what
one might call the core data of the disorder. This process itself has
been the subject of lengthy reviews (e.g., Joseph, Williams, &
Yule, 1997) and is likely to provoke healthy debate. Having
followed such a process of distillation, I endeavor in this section to
present what I feel to be core data of PTSD with respect to the
process of cognitive theorizing. I make no claims that this list
represents a consensus view among researchers in this area.

The Symptom Profile and Clinical Presentation of PTSD

Psychological distress following the experience of a traumatic
event has been discussed in the literature for over a century (e.g.,
Freud, 1919/1955; Janet, 1925; Putnam, 1898; Rivers, 1920). With
the inclusion of the category of PTSD in the third edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSMIII;
American Psychiatric Association, 1980), the constellation of psychological problems following a traumatic event achieved the
status of a formal psychiatric disorder. Within the fourth edition,
PTSD can follow a situation in which the person has experienced,
witnessed, or been confronted with an event that involved actual or
threatened death or serious injury . . . to oneself or others and the
persons response involved intense fear, helplessness, or horror
(Diagnostic and Statistical Manual of Mental Disorders, 4th ed.;
DSMIV; American Psychiatric Association, 1994, pp. 427 428).
Following the experience of such an event, to meet criteria for a
diagnosis of PTSD, the individual must present with symptoms
from three distinct clustersreexperiencing symptoms, avoidance/numbing symptoms, and hyperarousal symptomsfor at
least 1 month following the trauma and with a clinically significant
impairment in everyday functioning.

229

Reexperiencing symptoms include intrusive thoughts and images of the event, nightmares about the event, increased mental
and/or physiological distress on being reminded of the event,
and flashbacks during which individuals feel that they are
reliving the event in the present. The avoidance symptoms
include avoidance of situations, thoughts, or images associated
with the traumatic event and experiencing psychogenic amnesia
for the event. Numbing responses involve detachment from
others, restricted range of affect, and decreased interest in
activities in general (Litz, 1992). Hyperarousal includes symptoms such as sleep disturbance, poor concentration, attentional
hypervigilance to signals of danger, increased irritability, and
an exaggerated startle response; that is, excessive jumpiness to
loud or sudden noises.
There are individual differences in the course of PTSD reactions. The DSMIV distinguishes between acute, chronic, and
delayed-onset PTSD. Acute PTSD is diagnosed if the duration of
symptoms is less than 3 months and onset is greater than 1 month
posttrauma. Chronic PTSD (e.g., Davidson, Kudler, Saunders, &
Smith, 1990; Kilpatrick, Saunders, Veronen, Best, & Von, 1987;
Solomon, Kotler, Shalev, & Lin, 1989) is diagnosed if the duration
of symptoms is 3 months or more. Finally, PTSD with delayed
onset (e.g., McFarlane, 1996) is diagnosed if the onset of symptoms is at least 6 months after the original traumatic event.
Beyond the core symptom profile of PTSD, a number of other
aspects of the clinical phenomenology have attracted theoretical
and research interest (e.g., Dalgleish & Power, 2003; JanoffBulman, 1992; Power & Dalgleish, 1997; Reynolds & Brewin,
1998). The first of these is the often pervasive change in the
sufferers views of themselves and the world that can occur following traumawhat has been referred to as transformation of
meaning (Janoff-Bulman, 1989, 1992; Janoff-Bulman & Frantz,
1997). Pretrauma conceptualizations of the world as reasonably
controllable and predictable and the self as reasonably protected
are severely damaged by a traumatic event. The world becomes a
meaningless, uncontrollable, and unpredictable place in which the
self is vulnerable to random malevolence (e.g., Calhoun, Cann,
Tedeschi, & McMillan, 1998; Janoff-Bulman, 1992; Magwaza,
1999; Prager & Solomon, 1995; Solomon, Iancu, & Tyano, 1997;
Ullman, 1997).
Second, there is the emotional content associated with the disorder. This is referred to in a number of places in the DSMIV. For
instance, Criterion A refers to feelings of intense fear, helplessness or horror (American Psychiatric Association, 1994, p. 428)
at the time of the event. Furthermore, allied to the Criterion B
symptoms of reexperiencing is the notion of mental and physiological distress at reminders of the event. This emotional content
associated with PTSD can be usefully divided into two classes.
First, individuals report what they see as appropriate emotional
reactions to reflecting on a highly threatening event. Fear reactions
that are experienced when thinking about or going over the trauma
are viewed as reasonable responses to dwelling on an experience
that in reality threatened salient goals such as personal survival.
Similarly, fear reactions that concern the ongoing effect of symptoms and distress are also appropriate (Ehlers & Clark, 2000). I
refer to this class of emotional responses as appraisal-driven

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DALGLEISH

throughout the rest of the article.1 There is a burgeoning literature

indicating that such appraisal-driven emotions are important in the
course of PTSD, with a greater concentration of consciously accessible negative appraisals and concomitant emotions being associated with poorer prognosis (e.g., Dunmore, Clark, & Ehlers,
1997; Ehlers & Clark, 2000; Ehlers, Clark, et al., 1998; Ehlers &
Steil, 1995). Second, people with PTSD describe feelings of intense distress being automatically cued by reminders of the event,
even though the reminders, in and of themselves, may be nonthreatening (e.g., Brewin et al., 1996). This is reflected in the
DSMIV symptom profile, in which reminders of the event uncontrollably provoke psychological and physiological distress.2
Although fear is the dominant emotion in PTSD, sufferers are
frequently troubled by a range of other strong negative emotions
such as anger (Foa, Riggs, Massie, & Yarczower, 1995; Pitman et
al., 1991), guilt, shame, disgust, and sadness (Andrews, Brewin,
Rose, & Kirk, 2000; Dalgleish & Power, 2003; Grey, Holmes, &
Brewin, 2001; Jaycox & Foa, 1996; Reynolds & Brewin, 1998).
The presence and strength of these other emotions seems to have
important implications both for the treatment of PTSD (see below;
Foa & Rothbaum, 1998; Jaycox & Foa, 1996; Pitman et al., 1991)
and for recovery more generally, with anger and shame being
associated with a poorer prognosis (Andrews et al., 2000).

Factors Affecting the Course, Onset, Severity, and Nature

of PTSD
A number of factors appear to determine the course, severity,
and nature of posttrauma psychological reactions, and these have
been reviewed in detail elsewhere by various authors (e.g., Brewin,
Andrews, & Valentine, 2000; Ozer, Best, Lipsey, & Weiss, 2003).
Foa and her colleagues (Foa & McNally, 1996; Foa & Meadows,
1998; Foa & Riggs, 1993; Foa & Rothbaum, 1998) have usefully
divided these factors into three subsets: pretrauma factors, trauma
factors, and posttrauma factors, and this distinction is adopted
here.
A number of pretrauma risk factors for PTSD have been identified.3 First, several studies have indicated that a pretrauma personal psychiatric history predicts more severe posttraumatic stress
reactions (e.g., Atkeson, Calhoun, Resick, & Ellis, 1982; Bremner,
Southwick, Johnson, Yehuda, & Charney, 1993; Breslau, Davis,
Andreski, & Peterson, 1991; Burgess & Holmstrom, 1978; Hough
et al., 1990; Lopez-Ibor, Soria, Canas, & Rodrigues-Gamazo,
1985; McFarlane, 1988, 1989; North, Smith, & Spitznagel, 1994).
However, not all studies have found this relationship (Kilpatrick,
Veronen, & Best, 1985; Madakasira & OBrien, 1987; Solkoff,
Gray, & Keill, 1986; Speed, Engdahl, Schwartz, & Eberly, 1989).
Second, a family psychiatric history is also a significant risk factor
(e.g., Brent et al., 1995; Breslau et al., 1991). Finally, previous
exposure to trauma, particularly childhood abuse, appears to enhance vulnerability to developing posttraumatic emotional difficulties (e.g., Andrews et al., 2000; Bremner et al., 1993).
Trauma factors fall into two broad classes: factors that are
indicative of event severity and factors that represent the way in
which the event was interpreted or experienced at the time. Under
the umbrella of event severity, bereavement seems especially
related to more severe and chronic disturbance (e.g., Breslau et al.,
1998; Green, Grace, Lindy, Titchener, & Lindy, 1983; Joseph,

Yule, Williams, & Hodgkinson, 1994). However, exposure variables such as severe personal injury and threat to life also adversely influence the course of symptomatology (e.g., Foy, Sipprelle, Rueger, & Carroll, 1984). Consequently, the type of trauma
experienced is also related to the risk of developing PTSD, with
the highest risk being associated with assault and violence (Breslau
et al., 1998).
Under the umbrella of interpretive and experiential factors,
cognitions and appraisals at the time of the event have been
identified as predictive of later outcome. For example, Dunmore,
Clark, and Ehlers (1999) showed that mental confusion at the
time of the assault and a sense of mental defeat at the time of the
assault were associated with poor symptom prognosis (see also
Ehlers, Maercker, & Boos, 2000). Similarly, peritraumatic dissociation, in which the individual undergoes a dissociative experience at the time of the trauma, seems to be associated with a poorer
prognosis (e.g., Ehlers, Mayou, & Bryant, 1998; Koopman, Classen, & Spiegel, 1994; Murray, Ehlers, & Mayou, 2002; Shalev,
Peri, Canetti, & Schreiber, 1996).
The principal posttrauma factors that have been associated with
poorer outcome also fall into two broad classes: First is the nature
of the support that the traumatized individual receives. Victims
with more supportive relationships recover more quickly and evidence fewer symptoms than do victims without supportive relationships (e.g., Brewin et al., 2000; Burgess & Holmstrom, 1978;
Dalgleish, Joseph, Thrasher, Tranah, & Yule, 1996; Frye & Stockton, 1982; Kilpatrick et al., 1985).
Second is the way that trauma survivors interrogate and
interpret their experiences. Research on attributional style has
generally shown a relationship between better posttrauma outcome and a more internal locus of control (e.g., Affleck, Tennen, Pfeiffer, & Fifield, 1987; Baum, Fleming, & Singer, 1983;
Frye & Stockton, 1982; Tennen & Affleck, 1990; Timko &
Janoff-Bulman, 1985), though this is not true of all studies (e.g.,
Joseph, Brewin, Yule, & Williams, 1991, 1993). Furthermore,
Dunmore et al. (1999) showed that negative appraisal of symp1

The term appraisal is not theoretically neutral, referring as it does to a

major class of cognitive theories of emotion (Scherer et al., 2001). However, as appraisals are the dominant theoretical construct to refer to online
emotion generation in cognitive theories of emotion, I use the term here to
refer to that class of emotion generation in general.
2
Of course, it is possible that appraisal-driven emotions can present
themselves into conscious awareness without any such awareness of the
cognitive content of the relevant appraisals (Lambie & Marcel, 2002). The
difference between this scenario and the case of so-called automatic
emotions is that the appraisal-driven case involves contemporaneous, online appraisals of the object of the emotions, even though the individual is
unaware of the appraisals. In contrast, the automatic case does not involve
contemporaneous online appraisals. Rather, the automatic generation of an
emotion is a function of associative connections between the representation
of the object and that emotion that have been established at some time in
the past.
3
Because the focus of the article is on cognitive theories of PTSD, this
section omits biological risk factors. However, a number of such risk
factors for the onset of PTSD have been identified. For example, chronically low cortisol levels (e.g., Resnick, Yehuda, Pitman, & Foy, 1995;
Yehuda et al., 2000). For a review of this literature, see Yehuda (1999).

COGNITIVE MODELS OF PTSD

toms, perceived negative responses from others, and a sense of

having been permanently changed, all predict poor PTSD prognosis (see also Dunmore et al., 1997; Dunmore, Clark, &
Ehlers, 2001; Ehlers, Clark, et al., 1998; Ehlers et al., 2000;
Ehlers & Steil, 1995; Steil & Ehlers, 2000).

The Psychological Treatment of PTSD

The PTSD treatment studies that come closest to meeting the
gold standards of treatment trials of good outcome measures and a
randomized, blind design with manualized treatments (see Foa &
Meadows, 1998) have focused almost exclusively on variations of
exposure therapy and cognitive therapy (Ehlers et al., 2003; Foa,
Dancu, et al., 1999; Foa, Rothbaum, Riggs, & Murdock, 1991;
Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Resick,
Nishith, Weaver, Astin, & Feuer, 2002; Tarrier et al., 1999).
Exposure-based therapies involve clients systematically confronting the objects of their emotional distress within a therapeutic framework. The exposure-based element of these treatments most usually involves the client repeatedly recounting
the details of the traumatic event over exposure sessions. The
account is often delivered in the present tense and most usually
with emphasis on the cognitions and feelings associated with
various aspects of the narrative (see Foa & Rothbaum, 1998, for
a detailed description).4 Cognitive therapies variously target
clients interpretations of the trauma and its effect on their lives
and/or interpretation of the symptoms of PTSD and their significance. Cognitive therapy is often used to help the client to
deal with negative thoughts and feelings associated with exposure to the traumatic memory and to counteract posttrauma
transformation of meaning (see The Symptom Profile and Clinical Presentation of PTSD section).
The bottom line for the numerous treatments studies referred to
above seems to be that prolonged exposure, various forms of
cognitive therapy, and combinations of the two are all efficacious
in the reduction of PTSD symptomatology (with caseness remission rates as high as 70%) but that there is little evidence to support
the clear clinical superiority of either form of active treatment over
the other or for the superiority of combined treatments over unitary
treatments.
Increasingly, researchers and clinicians have become interested
in treatment nonresponders. For instance, Pitman et al. (1991)
presented a series of six case vignettes as a vehicle to discuss this
issue with respect to exposure therapy. As they noted,
Going over the situation again and again as called for in the flooding
procedure appeared to have the effect not of alleviating but rather of
exacerbating the anger, shame, guilt, self-accusation, feelings of failure, and what if rumination associated with performance in the
traumatic situation. Although flooding may be effective in making the
patient and therapist aware of the existence of negative post-trauma
appraisal, it may not be effective in resolving it. (Pitman et al., 1991,
p. 19)

Similar points have been made and expanded upon by Jaycox and
Foa (1996).

231

Proposed Evaluative Criteria for an Effective

Theory of PTSD
Criteria for Evaluating Theories as Accounts of PTSD
The core clinical and research data on PTSD reviewed briefly
above can be broadly divided into the following three classes:
PTSD presentation, recovery, and individual difference. Presentation refers to the clinical presentation and course of PTSD according to the DSMIV as well as two classes of emotional content
(appraisal driven and automatic) and transformation in higher
order meaning. Recovery encompasses the natural process of recovery and recovery as a function of both exposure therapy and
cognitive therapy. The third class includes data on PTSD and
individual differences in onset, course, and recovery (including
following psychological treatment) as a function of (a) differences
in pretrauma risk factors; this involves the factors identified as
most important in the recent Brewin et al. (2000) and Ozer et al.
(2003) meta-analysesnamely previous personal or family psychiatric history and previous experience of trauma in the form of
childhood abuse, (b) differences in the content and style of cognitive processing during the trauma and subsequently; this essentially includes variations in attributional style and content of appraisals along with dissociation, and (c) differences in trauma
severity (and thereby, trauma type).

Criteria for Evaluating Theories as Theories

As already noted, cognitive theories in psychology tend to have
a number of identifiable components. One or more types or levels
of mental representation are outlinedfor example, schemas, associative networks, or propositions. In addition, a number of
cognitive processes that act on those representations or on incoming information are describedfor example, memory, attention,
thinking, reasoning, emoting. Three issues are raised by the contents of this prototypical cognitive theory package.
The first issue is that of theoretical parsimony. It is clearly
possible to have as many representations and processes in ones
theory as there are things to explain in ones chosen data set. So,
for example, if the aim is to generate a model of word reading, one
option would be to have a representation for every form of a word
that one might encounter, that is, every font type, size, contrast,
and brightness, and so on. Alternatively, one could propose a more
abstracted representation of a word that represents all variations in
its visual appearance. It is more parsimonious in a theory to have
the minimal number of theoretical components at the maximum
level of abstraction. Such an approach has other advantages. Most
notably, theoretical components at greater levels of abstraction
4
There have been several studies that have examined a variation of
exposure therapy, eye movement desensitization and reprocessing (EMDR;
Shapiro, 1995), a technique that pairs exposure with eye movements
induced by asking the clients to follow the therapists moving finger with
their eyes. Many of these studies suffer from methodological problems, but
the results broadly suggest that EMDR is effective in reducing PTSD (e.g.,
Boudewyns, Stwertka, Hyer, Albrecht, & Sperr, 1993; Rothbaum, 1997;
Vaughan et al., 1994; Wilson, Becker, & Tinker, 1995), although it seems
that the eye movements themselves may not be necessary (Pitman et al.,
1996).

232

DALGLEISH

have the potential to speak to wider data sets. This ensures that
such accounts are more likely both to explain new empirical
findings within a domain and to have the potential to integrate new
domains of data. Balancing this desire for parsimony, however, is
the obvious fact that the theory needs to account for the whole
range of data in a given domain. This sets lower boundaries on the
minimum number of components in the theory. The optimal cognitive theory, therefore, has the minimum number of processes and
representations, and no more, to account for the data set under
consideration. Needless to say, many theories deviate from this
optimum standard. I call the need to marry the number of components in a theory to the demands of the data to be modeled the
number of components problem.5
The second issue concerns the way in which the interaction of
components in the theory is specified. As soon as a given theory
includes more than one component, be it a type of mental
representation or a type of cognitive process, there is pressure
on the theorist to provide an account of how the multiple
components interact with each otherin other words, an account of the mechanics of the theory. If this is not the case then
the theoretician can continue to add components in a completely
unconstrained way. Proliferating theoretical components will
always appear to buy greater explanatory power, and the multicomponent theory will always speak to more of the data than
the single component theory. However, without a formal account of how the different components interact, theories will
become increasingly vague and underspecified, and their utility
will be compromised as components are added. I call the need
to specify how different parts of a theory interact the interaction
of components problem.
The final issue is essentially a function of the degree to which
the number of components and the interaction of those components
are articulated and concerns the degree of specificity of a given
cognitive theory. This refers to the ability of a theory to account for
specific instances or patterns of empirical data, rather than just
broad empirical themes within the database. For example, a given
theory of PTSD may offer an explanation as to why negative
interpretations of trauma symptoms would prolong the disorder
(e.g., Dunmore et al., 2001). However, to what extent would the
theory in question explain why some negative interpretations but
not others are particularly toxic?
Cognitive theories have generally been able to sidestep this
issue, as the data sets that they are seeking to explain tend to
consist of predominantly positive empirical and clinical findings.
Although negative findings do exist, many remain unpublished for
good reason in that the statistical power is rarely present to
interpret them in terms of acceptance of a null hypothesis rather
than a mere failure to reject it (see Vasey, Dalgleish, & Silverman,
2003, for a discussion). Consequently, specific patterns of positive
and negative data in a given domain are rarely available as a true
test of theoretical specificity. However, theoreticians do have the
option of prospecting about data, as well as of offering retrospective accounts of existing findings. A well-specified theory should
be able to generate specific predictions that can be tested. For this
reason it is important that each theory is evaluated with respect to
what I call the specificity problem.

The Theories
In this section a number of cognitive theories of PTSD are
presented. The list is not intended to be exhaustive. Theories
presented have been selected because they are prototypical (rather
than singular) exemplars of classes of cognitive theory. The review
has been organized around the developing cognitive representational complexity of the theories, as opposed to their chronological
order of publication. Consequently, two theories that rely on a
single explicit type of cognitive representation are discussed first
(a schema-based theory and an associative-network-based theory).
Secondly, four theories that explicitly rely on different combinations of two or more representational components are outlined and
evaluated.

Schema-Based Theories
The term schema is used to refer to a way of mentally representing knowledge (Fiske & Linville, 1980). The task of schemas
is the organization of knowledge at different levels of abstraction.
By dint of such organization schematic representations bring order
to the chaos of a lifetime of myriad experiences through the coding
of the commonalities and regularities of those experiences and the
representation of them in the mind. For example, a restaurant
schema would code generic features of restaurants and visits to
restaurants, as a function of many individual restaurant experiences in a persons history. Schemas then are parsimonious mental
representations that serve as models of aspects of the world, the
self and other people. Consequently, the existence of schemas
obviates the need to mentally reinvent the wheel with each new
experience by providing a blueprint against which that experience
can be fitted.
By providing a preexisting representational structure against
which all incoming information can be compared and through
which that information can be filtered (Fiske & Linville, 1980),
schemas are necessarily partisan. Research indicates that information processing is biased in favor of maintaining the status quo
with respect to schema content. For example, people are relatively
better at remembering schema-consistent information (e.g., Swann
& Read, 1981), tend to make mnemonic errors in a schemaconsistent pattern (e.g., Cantor & Mischel, 1977), and interpret
new information so as to support preexisting schemas (e.g., Langer
& Abelson, 1974). For these reasons schematic knowledge is very
resistant to change and, normatively, schematic change takes place
slowly (Fiske & Taylor, 1991). The concepts of assimilation and
accommodation have been used to describe slow schematic change
(Piaget, 1952). New information is assimilated into schematic
structures by being selectively processed and stored in a schemacongruent manner. In addition, schema representations are themselves altered by small degrees by the accumulation of a critical
mass of schema-inconsistent information. It has been argued that
such conservatism regarding schema change is a function of an
5
On occasions, theorists discuss data but offer no real explanatory
account of those data in the theory. This can give the impression that a
certain data set is addressed by the theory when in fact it is not. Where this
is the case, the theories are (hopefully) appropriately called to account in
this review.

COGNITIVE MODELS OF PTSD

evolutionary need for existential stability and coherence in higher

order meaning structures (Janoff-Bulman, 1989; Nisbett & Ross,
1980).
However, schema change is not viewed as a uniformly slow
process. Piaget made the seminal proposition that slow schematic
change occurs up to a point when the existing schemas become
untenable as valid representations of the experienced world (see,
e.g., Piaget, 1952). At this juncture (or developmental stage, as
Piaget referred to it), old schemas are abandoned and new schemas
instantiated. Other authors have proposed rapid schema change
processes under different circumstances. For example, Rothbart
(1981) put forward the conversion model, in which he argued for
a relatively abrupt catastrophic change mechanism when schemas (stereotypes in his terminology) are faced with a minimal
number of salient, highly incongruent critical instances.
So what does the schema construct buy the aspiring cognitive
theorist in the domain of psychopathology? Essentially, schemas
deliver two very powerful explanatory principles concerning the
organization of knowledge. The first is the idea that regularities of
past experience, represented at different levels of abstraction, act
as filters through which all new experiences are processed. In this
way, an individuals current and past sense of reality is organized
in a schema-consistent manner. This idea allows the possibility of
individual differences in the content and nature of schematic
representations as a function of past experience, and it also follows
that dysfunctional schematic representations can have a potentially
profoundly disabling effect on moment-to-moment psychological
processing. The second explanatory principle is that new experiences or information that are significantly inconsistent with schematic representations are disruptive and lead schemas to either
assimilate or organize them in some way and/or become changed
by them (accommodation). The flagship schema-based approach to
psychopathology has been Becks cognitive therapy (e.g., Beck &
Emery, 1985; Beck & Freeman, 1990; Beck, Rush, Shaw, &
Emery, 1979), where the schema construct has been fruitfully
applied to problems ranging from anxiety disorders to
schizophrenia.
On the face of it, then, it is clear why schema theory has appeal
for theoreticians concerned with explaining PTSD. PTSD seems to
be critically about fitting the experience of the traumatic event into
ones prior understanding of things. The notion of schemas as
theoretical coinage for the representation of such prior understanding opens up possibilities for modeling changes in that understandingthe transformation of meaning referred to earlier either as
a result of the trauma or as a result of the recovery process.
Furthermore, individual differences in prior experience and their
influence on current mental health can be conceptualized as differences in the nature and content of schematic representations
that is, as differences in the way past knowledge has been organized from one person to the next.
There have been two principal applications of schema theory in
the domain of posttraumatic stress (though see also, e.g., Lawson,
1995). The first originating out of work in psychodynamic psychology (e.g., Horowitz, 1973, 1976, 1979, 1986, 1997; Horowitz,
Wilner, Kaltreider, & Alvarez, 1980), and the second derived from
work in social cognition (Janoff-Bulman, 1985, 1989, 1992;
Janoff-Bulman & Frantz, 1997; Janoff-Bulman & Frieze, 1983).
The work of Horowitz is discussed in detail as representative of

233

this general approach, though I note where Janoff-Bulmans approach differs significantly in emphasis.
Horowitzs formulation of stress response syndromes. Horowitzs (1973, 1976, 1979, 1986, 1997; Horowitz et al., 1980)
formulation of stress response syndromes has the distinction of
offering the first influential cognitive model of reactions to trauma,
notwithstanding its roots in classical psychodynamic psychology
(notably Freud, 1919/1955).6 Horowitz (1986, 1997) has argued
that the main impetus within the cognitive system for the processing of trauma-related information comes from a particular psychological process that he termed the completion tendency. This
reflects the psychological need to match new information with
inner models based on older information, and the revision of both
until they agree (Horowitz, 1986, p. 92). Horowitz derived his
formulation of completion from earlier work by Festinger (1957)
and Mandler (1964) and, in essence, the completion tendency can
be thought of as the driving force behind processes of schematic
assimilation and accommodation as meaning structures are continually updated and knowledge reorganized with respect to current reality.
Horowitz (1986, 1997) has proposed that, subsequent to the
experience of trauma, in the normative course of stress response
there is an initial crying out reaction in which the thoughts,
memories, and images of the trauma cannot be organized within
current meaning structures; that is, there is an initial failure to
complete. Horowitz (1986) suggested that, as a result, a number
of psychological defense mechanisms come into play to keep the
traumatic information in the unconscious and to prevent entry into
distraught, overwhelmed states of mind (p. 95). Consequently,
the individual then experiences a period of numbing and denial.
Horowitzs (1986) position is in line with the fundamentally conservative nature of schematic change discussed above, in which
cognitive processing is biased in favor of maintaining extant (in
this case, pretrauma) schematic structures.
Horowitz (1986, 1997) argued that (by virtue of the completion
tendency) during such defensive maneuvers trauma-related information is maintained in what he termed active memory. This is a
type of memory with motivational properties that has an intrinsic
tendency to repeat its contents into conscious awareness until
successful completion has been achieved. Active memory of the
trauma thereby causes traumatic information to break through
psychological defenses in the form of flashbacks, nightmares, and
unwanted thoughts (the reexperiencing symptoms of PTSD). According to Horowitz, this tension between the completion tendency
on the one hand and the psychological defense mechanisms on the
other causes individuals to oscillate between phases of intrusion
and denial-numbing as the traumatic material is gradually assimilated into long-term schematic representations, causing it to be
slowly cleared from active memory storage. As a corollary to
this slow schematic change, Janoff-Bulman (1985) in her model
argued that to the extent that particular assumptions are held with
extreme confidence and have not been challenged, they are more
6
It is important to note that often in his writings Horowitz did not talk
exclusively about PTSD but about response to trauma more generally.
However, the ideas are applicable to PTSD.

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DALGLEISH

likely to be utterly shattered, with devastating results for the

victim (p. 23)this is the rapid schema change described earlier.
In Horowitzs model, particularly in its later instantiations (e.g.,
Horowitz, 1997), there can exist more than one schema with the
same referent, such as the self:
Every person has not just one self-schemata or version of interaction
between the self and others, but multiple inner models of role and
relationship sequences. The dominant schema used to organize a train
of thought influences the concepts and emotions that occur during the
thought sequence. (Horowitz, 1997, p. 105)

In other words, knowledge is organized by repertoires of schemas

and the dominant or supraordinate self-schema at a given time is
what controls the organization of new information.7 Individual
differences in traumatic stress response in Horowitzs model derive from variations in pretrauma supraordinate schema content as
well as from variations in the effectiveness of the defensive maneuvers that protect the supraordinate schemas from the representation of the trauma in active memory. In his discussion of individual differences in stress response, Horowitz (1997) focused on
the latter source of variation.8
For example, a failure to complete can arise out of nonoptimal
levels of defensive control, and mean that the partially processed
traumatic information remains in active memory without ever
being fully assimilated. This would lead to chronic post-traumatic
reactions. In contrast, dealing with trauma-related information by
a process of systematic inhibition would lead to a presentation
characterized by denial, repression, suppression, isolation, numbing, dissociation, use of drugs, flight or suicide as avoidance
(Horowitz, 1997, p. 108). Such individuals may also be vulnerable
to emotional flooding when these defenses break down in the
form of delayed-onset PTSD.9 In addition, a third source of individual differences was proposed by Janoff-Bulman (1989), who
suggested that the flexibility or viability of schemas (assumptions) might also be associated with problems in coping: In the
end, the victim must have a viable assumptive world, one that is
able to account for the data of his or her victimization experience
(p. 124).
Evaluation of schema-based theory as an account of PTSD.
The first point that emerges from an analysis of schema-based
theory is the impressive explanatory power that has been achieved
by taking a single representational format10 and exploring the
range of its application to a form of psychopathology. Schema
models of PTSD are able to account for far more of the core data
of the disorder than they fail to account for. Schema-theories of
PTSD achieve this by utilizing the two main explanatory principles
described earlierthat the content and nature of schematic representations determines how all new information is processed and
that new, schema-incongruent information is problematic to such
processing. The application of these two principles to trauma
generates a robust account of the central symptoms of PTSD
(American Psychiatric Association, 1994). Reexperiencing symptoms are conceptualized as the intrusion into consciousness of
trauma-related information stored in some form of active memory
that cannot be readily organized by extant schemas. The thesis is
that such repetition of the trauma is an integral part of the process
of gradually assimilating the traumatic information into pretrauma
schemas. Hyperarousal symptoms are seen as reflecting the exis-

tence of such trauma-related information in active memory. There

are nevertheless some issues associated with the concept of active
memory, and these are discussed in the next section evaluating
schema theory as a theory. Avoidance symptoms in schema-based
theory are seen as necessary defensive maneuvers to regulate the
pace of the schematic change process and prevent the system
entering a state of emotional overload. Because schema accounts
focus on such schematic change, they represent robust models of
the transformation of meaning following trauma. However, it is
less clear how emotions fit into schema-based theory. Although
there is much discussion of emotions by schema theorists, it is not
explicit how, say, shame, might arise as a function of a traumatic
experience. This is true for both automatically generated and
appraisal-driven emotions.
The normative course of PTSD recovery within schema-based
theory is a straightforward function of the gradual assimilation of
the trauma-related material into pretrauma schema structures. The
efficacy and effectiveness of exposure therapy is also covered by
schema theory. However, it is not explicit why exposure therapy is
so much more beneficial than the natural oscillation of intrusion
and avoidance for many individuals. However, this may say more
about the available data on what the key ingredients are in exposure therapy than about schema theory. It is plausible, for example,
7

Such variations in an individuals state of mind as a function of the

dominant set of schemas have been referred to by Teasdale (1997) as
reflecting the mind in place.
8
Janoff-Bulmans work, in contrast, is more clearly focused on offering
a description of the modal content of schematic representations prior to
trauma, which are divided into the following three clusters on the basis of
interview and questionnaire data (e.g., Janoff-Bulman, 1989; JanoffBulman & Frieze, 1983): the benevolence of the world, the meaningfulness
of the world, and the worthiness of the self.
9
Horowitz (1997) identified two other principal defensive maneuvers:
firstly, switching and secondly, sliding to alter valuation. Switching is
a term used to describe systematic distraction by the trauma survivor:
switching to alternative themes which jam the representational systems
and prevent painful recognition of the warded off contents (Horowitz,
1997, p. 169). Sliding the meaning of the trauma might include exaggerating or minimizing it, displacing the distress caused onto something
else and polarizing good and bad with good things internalized and bad
things externalized. Horowitz (1997) contextualized these three key defense processes within the psychodynamic literature on personality. Thus,
inhibition equates to a pretrauma hysterical personality style (Janet, 1907),
switching equates to an obsessional style (Freud, 1909/1955), and sliding
of meaning equates to a narcissistic style (Freud, 1914/1957). By applying
such a framework, Horowitz (1997) was able to propose how particular
courses of posttraumatic symptomatology map onto pretrauma configurations of schematic representations and processes.
10
Despite an explicit focus on schematic representations in the theories,
it remains slightly unclear how schematic knowledge is actually represented. In Horowitzs model this issue is not explicitly discussed. In
Janoff-Bulmans writings it is proposed that assumptions about the world
and the self are highly abstracted knowledge structures, established as the
result of the individuals entire learning history. However, Janoff-Bulman
also seems comfortable in describing such representations in terms of
propositional statements in natural language her basic assumptions. It
seems likely that such abstracted knowledge structures are too complex to
be captured propositionally in this sense, and this problem is left unresolved in her model.

COGNITIVE MODELS OF PTSD

that exposure therapy would be helpful for those individuals who

are overly defended such that effective emotional processing
(Rachman, 1980) of the trauma-related information is blocked, but
this falls short of accounting for the pervasive benefits of exposure
in the treatment of posttraumatic stress (e.g., Foa, Dancu, et al.,
1999; Marks et al., 1998). Schema-based theory offers a plausible
rationale of the effects of the various forms of cognitive therapy
for PTSD (though not the mechanism; this is discussed below in
the Evaluation of schema-based theory as a theory section). For
example, in Horowitzs writings, a great deal of space is devoted
to how particular interpretations in therapy can facilitate the integration of trauma information into existing schemas. Any therapeutic program that targeted this domain would therefore be likely
to reap mental health benefits.
Regarding individual differences in posttraumatic stress reactions, Horowitz (1991) discussed how failure to regulate the defense of traumatic information can lead to chronic intrusion and
chronic PTSD and also identifies a number of pretrauma schema
typologies that help determine the course of the disorder. Similarly, Janoff-Bulman (1989) discussed how nonviable or inflexible
assumptions about the world and the self can lead to catastrophic
schema damage that may be hard to recover from. These ideas also
generally provide a good explanatory handle on the role of pretrauma factors in determining the course of PTSD.
Schema-theory also offers a good account of the effects of
trauma factors on the course and severity of PTSD. It is clear how
factors such as personal injury, threat to life, bereavement, and
negative cognitions that are associated with a greater mismatch
between trauma-related information and preexisting schemas
would lead to more severe PTSD. Similarly, arguments can be
made that any barriers between trauma-related information and the
self-schema, such as peritraumatic dissociation, make later integration of these representational structures more difficult. With
respect to posttrauma factors such as attributions, the counterintuitive predictions from Janoff-Bulmans ideas are that self-blame
following a traumatic event would be predictive of better outcome,
as it would serve to maximize a sense of control of the situation.
This is in line with the majority of the data (e.g., Janoff-Bulman,
1989; Timko & Janoff-Bulman, 1985), though see Joseph et al.
(1991, 1993) for exceptions.
Schema-based theories of PTSD also offer some pointers as to
why treatment might fail for some individuals. The suggestion that
preexisting schematic representations are not viable enough
(Janoff-Bulman, 1989) to assimilate trauma-related information
indicates that treatment may not be beneficial. Similarly, excessive
defensive maneuvers, as discussed by Horowitz (1986, 1997),
would also plausibly be associated with poor treatment outcome. It
is also possible to see how prolonged exposure-based therapies
could make some clients worse in that their defensive control of
the pacing of the assimilation of trauma-related information would
be compromised. In addition, the exposure process might instigate
trauma-related cognitions that the clients do not feel equipped to
deal with (Ehlers & Clark, 2000).
Evaluation of schema-based theory as a theory. One issue for
schema-based theory concerns the account it offers of the automatic nature of some PTSD symptoms. Central to the diagnostic
criteria of PTSD is the idea that intrusive thoughts and emotions
about the trauma are triggered by myriad reminders and cues.

235

These aspects of the presentation of the disorder are not covered in

Janoff-Bulmans PTSD account though they are addressed in
Horowitzs theory by the notion of active memory. However, this
concept of active memory seems underspecified in that it is neither
clear what type of mental representation it is nor how it relates to
existing cognitive theories of memory. Is it, for example, another
form of schema? Is it supposed to include information that is
represented in various different ways? A related issue is that it is
not apparent how the mismatch between the trauma information
(in active memory) and schematic knowledge is resolvedwhat is
the process of schema change?
A second issue concerns the lack of a language-based, referential representational format (propositional representations) in
schema theories. PTSD is associated with negative thoughts, interpretations, attributions, and so on about the trauma, as well as
with appraisal-driven emotions. What is more, the rational,
language-based intervention of cognitive therapy is effective in
treating PTSD. Although it seems clear from the theories discussed
that such language-based cognitive processing may result from the
conflict between the content of preexisting schemas and that of the
trauma (and furthermore that cognitive therapy may be targeted at
resolving this conflict), it is not really clear how this is supposed
to take place. Where are thoughts and beliefs represented? And by
what means are they examined, manipulated, and changed? This is
not to say that such things are not discussed by schema theorists
but to point out that they are guilty of a theoretical sleight of hand
in that such discussion is not underpinned by an appropriate degree
of representational architecture. This lack of an explicit mental
representation for referential meaning in these theories is an example of the number of components problem.
The fact that several of the key components to support the
theoretical discourse of schema-based theory are underspecified
serves to compromise the specificity of the approach. This is
perhaps most usefully illustrated by an example. Foa and colleagues (e.g., Foa & Riggs, 1993; Foa & Rothbaum, 1998) have
suggested that a clear prediction of traditional schema theory
would be that preexisting schematic representations of the world
and the self that are highly negative should protect the individual
from the development of PTSD by virtue of the fact that they
preclude a mismatch between the trauma and preexisting meaning
structures; indeed, this should on the face of it to be one of the core
claims of a schema approach. However, as reviewed earlier, the
data pertaining to this issue suggest that a pretrauma history of
psychological problems is predictive of more, not less, severe
posttraumatic stress (e.g., Brewin et al., 2000). Similarly, having a
history of past traumas is related to a poorer prognosis (Brewin et
al., 2000; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). At
first blush, then, this suggests that a clear prediction of schemabased theory has been disconfirmed. However, schema theories
can deal with apparent problems such as this without breaking
stride by generating alternative predictions that can account for the
data through the use of aspects of the theory that are underspecified. For example, Horowitz (1986) proposed that pretrauma negative schemas can still lead to reexperiencing and avoidance of the
trauma by virtue of a number of maladaptive control processes
such as strong inhibition of trauma-related material, which then
breaks through into conscious awareness (see Janoff-Bulman,

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1992, for further discussion of ways in which schema theory deals

with these issues).
In summary, schema-based theories of PTSD offer a robust
account of many aspects of the core data of the disorder. They
offer a less complete account of the automaticity of PTSD symptoms; the emotions associated with PTSD; the mechanism of
schema change; and how referential information such as thoughts,
beliefs, appraisals, and the like is represented and manipulated
(e.g., in cognitive therapy). A number of these issues concern the
status of schema theories as theories, rather than as accounts of
PTSD. These theory-related issues also compromise the ability of
schema theory to account for specific patterns of empirical data or
to generate clear predictions.

Associative Network Theories

As with schema approaches, network theories in psychopathology promote a single aspect of mental representations as a parsimonious way of explaining a diverse set of data. Whereas the
strength of schema theories is the organization of abstracted
knowledge, the principal advantage of a network theory is the
connectivity between different representations. What network theory gives the theorist, therefore, is a representation of how disparate pieces of information can activate each other and lead to the
generation of affect (e.g., Bower, 1981). This has obvious appeal
to theoreticians of PTSD, with its core features of intrusive
thoughts, images, and emotions cued by a range of reminders
about the trauma. There are a number of such network theories of
PTSD in the literature (e.g., Chemtob, Roitblat, Hamada, Carlson,
& Twentyman, 1988; Creamer, Burgess, & Pattison, 1992; Foa et
al., 1989; Tryon, 1998, 1999; Yates & Nasby, 1993) emerging
from a broader tradition of conditioning theory within the domain
of psychotraumatology (e.g., Keane, Zimmering, & Caddell, 1985;
Pitman, Shalev, & Orr, 2000). The most fully articulated network
theory is the early work of Edna Foa and colleagues, which is
discussed as prototypically representative of network approaches
in general.
Foa et al.s (1989) fear network account of emotional processing. Foa et al.s (1989) fear network account of emotional processing in PTSD is predicated on an earlier model of the mechanisms of exposure therapy in anxiety disorders (Foa & Kozak,
1986). Foa and Kozak (1986) in their seminal article set out to
address the deceptively simple question of how exposure therapy
for anxiety disorders (see the beginning of this article for a brief
description of this intervention) reduces fear reactions. They proposed a fear networkan associative network in long-term memory consisting of three elements: stimulus information about the
feared object(s); information about cognitive, behavioral, and
physiological reactions to the feared object(s); and information
that links these stimulus and response elements together. They
proposed that in anxiety disorders such a fear network is pathological and acts as a fear program that is activated when one or
more of the elements in the network is encountered, producing a
fear reaction. The task of treatment, Foa and Kozak argued, is to
modify the fear network so that it is no longer dysfunctional.
Foa and Kozak (1986) proposed that fear network modification
requires two things: activation of the network so that the person
experiences fear and the integration of new fear-incompatible

elements into the network so as to change its fundamental structure. The argument is that exposure therapy satisfies both of these
conditions by means of two mechanisms. The first is extinction of
the fear reaction to the feared stimulus as a function of repeated
exposure. The second mechanism is cognitive. Expectancies regarding the predicted experience of exposurethat it will be
unbearable, that the anxiety will spiral out of control, that the
anxiety will persist indefinitelyare disconfirmed by the actual
experience. Extinction, it is suggested, provides feedback to the
client that anxiety reduces, that it does not spiral out of control, and
that it is not as severe as anticipated. The integration of these
new-meaning elements into the network facilitates network modification and is the proposed vehicle by which between-session
habituation to the feared object occurs. Finally, Foa and Kozak
argued that ineffective evocation and hence activation of the fear
network, inadequate duration of exposure, a paucity of fearincompatible information to incorporate, and high levels of denial
on the part of the client, can all lead to treatment nonresponse.
Foa et al. (1989; see also Foa & McNally, 1996) used the basic
framework of Foa and Kozak (1986) to propose a fear network
model of PTSD and to provide an account of how trauma-related
information is emotionally processed (Rachman, 1980). They proposed that the fear network for a traumatic event would be bigger
than that for a feared object in the other anxiety disorders (e.g.,
specific phobias). Furthermore, because traumatic events normatively violate rules of safety, there would be elements in the
network representing previously safe aspects of the individuals
environment. The fear network of Foa et al. (1989), in essence, is
a memory record of the trauma. An example of a pathological fear
network following trauma is presented in Figure 1. As noted
above, it contains stimulus, response, and meaning elements capturing the information relating in this case to the trauma of rape.
The reexperiencing symptoms of PTSD are seen as resulting
from activation of one or more elements in the fear network by
external stimuli. For example, in the network schematized in
Figure 1, encountering a bald man may lead to intrusive symptoms. This is a somewhat different account to that offered by
traditional schema theory (e.g., Horowitz, 1997) which conceptualizes reexperiencing symptoms as resulting from the unintegrated
nature of traumatic information and its consequent representation
in so-called active memory. Avoidance/numbing symptoms in
network theory are viewed as a mechanism by which the individual can minimize the risk of activation of the network and thus the
frequency of reexperiencing symptoms by minimizing contact
with congruent stimuli. Hyperarousal symptoms are not explicitly
discussed by Foa et al. (1989) but plausibly result from continuous
low level activation of the fear network.
The theory behind the modification of the fear network in
recovery from PTSD remains a function of the principles outlined
by Foa and Kozak (1986) and focuses closely on the treatment of
exposure therapy. For example, continuing with the example schematized in Figure 1, prolonged exposure to, for instance, (benign)
tall men should lead to modification of the fear network in two
ways. First, fear would extinguish to the stimulus. Second, as it
became clear that nothing bad was going to happen, this fearincompatible information could become integrated into the network. Repeated exposure over a number of sessions to a variety of

COGNITIVE MODELS OF PTSD

237

Figure 1. A schematic representation of a fear network following rape. PTSD ! posttraumatic stress disorder.
From Treating the Trauma of Rape: Cognitive Behavioral Therapy for PTSD (p. 76), by E. B. Foa and B. O.
Rothbaum, 1998, New York: Guilford Press. Copyright 1998 by The Guilford Press. Adapted with permission.

stimuli should eventually disarm the network.11 Such fear network

modification can occur as a function of repeated exposure to the
trauma memory within either a therapeutic or social support context. Despite offering such a clear account of recovery from PTSD
through prolonged exposure, it is less clear how network theory
can account for the efficacy of cognitive therapy in the treatment
of PTSD (see the Evaluation of network theory as an account of
PTSD section).
Network theory deals with a number of individual difference
factors in posttrauma response. Pretrauma psychiatric history, previous experience of trauma and trauma severity can all serve to
potentiate the fear network that is established. It is less clear,
however, how different types of trauma-related and posttrauma
cognitions might affect symptom course, though reference has
been made to erroneous evaluations (Foa et al., 1989, p. 171).
In network theory considerable emphasis is placed on the reasons for treatment nonresponse. In addition to the possible reasons
for such nonresponse outlined by Foa and Kozak (1986), Foa et al.
(1989) proposed other possibilities. The first is that treatment
failure may be a function of excessive arousal such that the
mechanisms of change of the fear network are unable to operate.
The second is the persistence of erroneous evaluations and interpretations in the face of corrective information (Foa et al., 1989,
p. 171). So, for example, genuinely safe situations during therapy
may still be represented as dangerous. Third, Foa et al. (1989)
elaborated on the theme of avoidance as a barrier to successful
emotional processing and introduced the notion of superavoidersindividuals who are extremely heavily defended from the
trauma and for whom successful activation of the fear network is
difficult. This is reminiscent of Horowitzs (1986, 1997) work on

different forms of defensive maneuvers in dealing with trauma.

Finally, Foa and McNally (1996) also suggested that the predominance of other emotions, such as guilt and anger, that are based on
appraisals of the traumatic event can interfere with recovery because they may not extinguish in the same way that fear does.
Evaluation of network theory as an account of PTSD. The aim
behind the development of the network model of PTSD was to
provide a coherent account of trauma memory records as a vehicle
for explaining the mechanism of operation of prolonged exposure
as a treatment. The network account was therefore deliberately
selective in its focus, and later theoretical writings by Foa and
colleagues (Foa & Meadows, 1998; Foa & Riggs, 1993; Foa &
Rothbaum, 1998) offer a more elaborated model incorporating the
idea of schematic representations. This expanded theory is considered later in the present article.
This caveat in mind, associative network theory as presented by
Foa et al. (1989) nevertheless provides an impressive account of
many of the core data of PTSD. As with schema-based approaches,
network accounts of PTSD are testimony to the explanatory power
of models in psychopathology that concentrate on a single aspect
of mental representations. The strength of network theory, unsurprisingly, resides in the theorys ability to model the connectivity
between different representations. This accounts for the basic
11
Foa and McNally (1996) addressed Boutons (1988, 2002; see also
Bouton & Schwartzentruber, 1991) proposal that old associations between
elements of the fear network are not erased but rather superimposed on by
new associations. That is, fear reduction is a function of new learning, not
unlearning.

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DALGLEISH

PTSD symptomatology as discussed above. It also provides a

modus operandum for the normative course of recovery from
PTSD through the integration of new information into the network
over time. Analogous mechanisms are proposed for the mechanism
of action of exposure therapy. Similarly, it is clear how the
pervasiveness of the network would relate to individual difference
factors such as augmented PTSD to more severe traumas. Individual differences in course of PTSD and response to treatment are
also a function of the pervasiveness of the network and the ease
with which new information can be integrated into it.
However, by focusing on the connections between representations, network theory does not take advantage of the explanatory
power available from processes that work directly on the content
of the representations themselves. One upshot of this is that network theory lacks a means by which representational content can
be directly manipulated by processes grounded in natural language. This means that it has difficulty in explaining how cognitions are interrogated and changed within the theory. This is
important both with respect to accounting for the data on traumarelated and posttrauma interpretations of the event as well as to the
process through which cognitive therapy is so efficacious. Related
to this, although network theory optimally accounts for automatic
emotions that individuals experience following trauma (via the
activation of emotion programs), it is not clear how appraisaldriven emotions are underpinned by the theory, as they do not rely
on simple connectivity between network elements.
Associative fear networks as they pertain to PTSD are relatively
traumacentric. That is, fear networks are principally representations of the trauma, including any stimuli that tangentially relate to
it. This contrasts markedly with schemas, which represent the
broad canvas of world, self, and others against which the trauma
and its implications are evaluated. Although it is possible for
networks to incorporate components of abstracted information
(e.g., the uncontrollable node in Figure 1) in the same way that
they can incorporate components of referential information, there
is again no explicit way in which the content of such abstracted
representations of the world and the self can be modified in the
original fear network approach (Foa et al., 1989). There is some
acknowledgment of higher order meaning concepts in the suggestion that the pervasiveness of the fear network in PTSD is a
function of the trauma having violated basic rules of safety. However, there is no substantive discussion of how such rules might be
represented. As a result of this, in theoretical terms it is not
completely clear how the trauma victims sense of meaning is
transformed as a result of the event or how it might be restored
following successful exposure therapy, although these issues are
more fully discussed in later work by Foa and colleagues (see The
Integrated Model of Foa and Colleagues section). Similarly, it is
not immediately clear how pretrauma risk factors for the development of PTSD are easily modeled within fear networks. For
example, how exactly does prior psychiatric history or experience
of trauma potentiate the development of fear networks in individuals vulnerable to PTSD?
Evaluation of network theory as a theory. As with schema
theory, network approaches fall foul of the number of components
problem in that the focus on connections between information
components means that there is no explicit representational archi-

tecture underlying referential meaning nor generalized, abstracted

knowledge in the model, as already discussed above.
The number of components issue, it may be argued, also has
more pervasive effects in the case of network theory. Specifically,
the lack of an explicit representational architecture for processing
cognitive content may present difficulties for the proposed account
of exposure therapy that is the heart of the model. The original Foa
and Kozak (1986) theory discusses the mechanisms of exposure
therapy partly in terms of the realities of exposure being less
aversive than the individuals expectancies; for instance, anxiety
extinguishes rather than spirals out of control. Consequently, there
is a need for expectancies to be represented in some way, and there
is a need for a representational forum in which the comparison
between expectancies and reality can take place. Without this sort
of representational space within the model, it is unclear how a
straightforward associative network can service the processing
needs for the cognitive mechanisms implicated in exposure therapy for PTSD and other anxiety disorders (Foa & Kozak, 1986).12
As with schema theory, the fact that network theory has problems
in terms of the number of components that are explicitly articulated has consequences for its ability to generate specific predictions and accounts of the extant data.
In summary, associative network theory again offers a strong
account of many of the core data of PTSD. It is less convincing in its
explanation of the transformation of meaning following trauma, the
processing of cognitions (including the mechanism of cognitive therapy), the mechanism of action of some pretrauma risk factors, and the
process by which appraisal-driven emotions might be generated.
Again, these question marks do not arise because these data are
ignored by network theorists but because, arguably, the appropriate
number of representational components is not present to fully account
for them (the number of components problem).
Interim summarytheories that focus on a single explicit aspect
or format of mental representation. In this section I have considered two classes of theory of PTSD that focus on a single
explicit aspect or format of mental representation. Schema approaches concentrate on providing an account of generic, abstracted representations of self, world, and others rather than on
just the trauma itself. The positioning and integration of the trauma
12
Foa and McNally (1996) discussed this issue of connections versus
content and highlighted the need for meaning structures other than associative links in a memory representation. They emphasized the distinction
between propositional (referential) and nonpropositional meaning associated with a trauma. Using the example of a dog phobia, they submitted that
fear network associations between dog and bite are nonpropositional in
that they cannot be fully represented by statements in natural language that
have a truth value. In contrast, propositionally represented information
such as dogs are dangerous can be represented, without any loss of
meaning, in natural language as statements that have a truth value. The
purpose of this distinction is that nonpropositional associations can only be
altered by exposure that replaces them with a less pathological alternative.
For example, exposure to nonbiting dogs will weaken the associative link
between dog and bite. In contrast, propositionally coded information
can be altered by the presentation of incompatible information linguistically via cognitive therapy techniques. However, in the Foa and McNally
discussion, it is unclear what the implications of this distinction might be
for the traditional network model of PTSD discussed here.

COGNITIVE MODELS OF PTSD

into these abstracted meaning structures is what does the theoretical work. In contrast, network approaches are relatively more
traumacentric, and it is the connectivity between information,
centered around the core traumatic experience, that is the driving
force of the theory.
What is impressive, therefore, is that two very different unirepresentational approaches can provide such robust accounts of PTSD.
What is more, the two approaches are potentially complementary
rather than mutually exclusive. This complementarity indicates that
any gaps left by either approach potentially might be filled by models
that combine more than one representational format. Such a shift to a
multirepresentational analysis would obviate some of the criticisms of
unirepresentation theories as theories, in that it would begin to address
the number of components problem and would provide a greater
potential to deal with the specificity problems of the unirepresentational approaches. However, the shift from a uni- to a multirepresentational approach presents a fresh nettle to grasp as it raises the
question of how the different types of representation relate to each
other (the interaction of components problem). Furthermore, although
such a shift should buy the theorist more explanatory power, it also
makes the theory more complicated and less accessible to, for example, clinicians who want a framework for the treatment of PTSD to
discuss with their patients. In the next section a number of theories
that involve more than one explicit form of mental representation are
discussed, and these potential disadvantages and advantages are
evaluated.

Theories With Two or More Explicit Representation

Formats
Dual representation theory (DRT). Brewin et al. (1996) have
applied Brewins (1989) DRT to PTSD (see also Brewin, 2001).

239

The first of the two types of representation in DRT reflects the

individuals conscious experience of the traumatic event. This
forms what Brewin et al. (1996) have called verbally accessible
memories (VAMs). VAMs are characterized by their ability to be
deliberately retrieved and progressively edited by the traumatized
individual. Furthermore, VAM representations are fully contextualized within the persons autobiographical database. The second
type of representation consists of situationally accessible memories (SAMs). SAMs contain information that cannot be deliberately accessed by the individual and that is not available for
progressive editing in the way that VAMs are. In fact, SAMs, as
the name suggests, are accessed only when stimuli redolent of the
original traumatic situation cue their activation. SAMs are not seen
as being contextualized within the autobiographical database. DRT
proposes that VAM and SAM representations are encoded in
parallel at the time of the trauma and between them account for the
range of PTSD phenomenology. For example, holistic, dissociative
memories or flashbacks, dreams, and trauma-specific emotions
would be considered to be the result of the activation of SAM
representations (via cueing), whereas peoples ability to recount
the trauma, for example in a therapeutic situation, their intrusive
memories of the conscious experience of the trauma, and affect
related to trauma-related and posttrauma cognitions would be a
function of accessing VAM representations. Avoidance symptomatology, as with both schema theory and network theory, is conceptualized as a range of techniques for dealing with unwanted
reexperiencing via VAM and SAM activation (in this case). See
Figure 2 for a schematic illustration of DRT.
As with network theory (and unlike schema theory), DRT is
essentially a traumacentric model of the disorder. SAMs and
VAMs center around the core traumatic event, rather than focusing

Figure 2. A schematic diagram of the dual representation theory of posttraumatic stress disorder. From A
Dual Representation Theory of Posttraumatic Stress Disorder, by C. R. Brewin, T. Dalgleish, and S. Joseph,
1996, Psychological Review, 103, p. 676. Copyright 1996 by the American Psychological Association. Adapted
with permission from C. R. Brewin.

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DALGLEISH

on generic aspects of self, world, and others. However, the elaboration of VAM representations in DRT marks a crucial (theoretical) evolutionary advance from the earlier network models (e.g.,
Foa et al., 1989). VAMs are propositional representations. That is,
their content can be translated into natural language without loss of
meaning. In this sense, the VAM system is a referential system
where the representations that it contains refer to other entities, be
they autobiographical events such as the trauma, beliefs, thoughts,
emotions, distillations of higher order meaning (such as schemas)
and so on. This is all well and good. Associative networks contain
such referential information (e.g., baldman in Figure 1). The
difference is that in DRT the proposal of a separate VAM system
provides a vehicle via which the referential content associated with
the trauma can be manipulated, evaluated and edited within the
same lingua franca. In contrast, associative networks are concerned with the connections between referential representations
and other network elements and not with how referential content
might be processed. The capacity to process referential content is
essential for any model that hopes to provide a convincing account
of cognitions, thoughts, attributions and so on and the changes in
these constructs following, for example, cognitive therapy. Essentially, then, DRT can be thought of as a network theory (SAMs) in
which one of the traditional types of networked nodesreferential
representations has been separated off and elaborated in the form
of VAMs.
Brewin et al. (1996) proposed that the emotional processing of
trauma essential for recovery from PTSD (Rachman, 1980) needs
to proceed via both the VAM and SAM representations to be
successful. They proposed that individuals need to consciously
integrate the verbally accessible information in VAM with their
preexisting beliefs and models of the world and to reduce negative affect by restoring a sense of safety and control, and by
making appropriate adjustments to expectations about the self and
the world (Brewin et al., 1996, p. 677). The second emotional
processing element, it is suggested, is the activation of information
in SAM through exposure to cues concerning the event. In fact, as
Brewin et al. (1996) pointed out, this would usually happen automatically when the individual begins to progressively edit VAM
information. Alterations in SAM representations can then occur
via the integration of new, nonthreatening information into the
SAMs or, more commonly (Brewin, 1989, 2001), by the creation
of new SAMs. These two proposed routes to successful emotional
processing are derivative of the theoretical ideas reviewed earlier.
The editing of VAM information to bring it into accord with
preexisting models of the world owes much to the accounts found
in the schema theories of Horowitz and Janoff-Bulman, whereas
the requirement of activation and the subsequent integration of
new information into SAMs is reminiscent of Foa et al.s implementation of fear networks (see above; Foa et al., 1989).
It is these two routes to successful emotional processing that
underpin the effective operations of exposure therapy and cognitive therapy in DRT. Exposure therapy is seen as bringing about
changes in SAM representations in much the same way as Foa et
al. (1989) have discussed the mechanics of change in fear networks
(see also Foa & Kozak, 1986). Brewin and colleagues (see particularly Brewin, 2001) have emphasized the creation of new SAMs
that overlay the existing ones, but as I have already discussed (see
Footnote 11), this possibility has also been promoted by Foa and

McNally (1996) with respect to associative networks. Cognitive

therapy, on the other hand, utilizes the referential VAM representations and allows the individual to integrate and manipulate the
trauma narrative and its associated cognitions, appraisals, attributions, and so on via progressive, intentional editing.
Brewin et al. (1996) discussed individual differences in trauma
response in terms of successful (or otherwise) emotional processing of VAM and SAM information concerning the trauma. They
suggested that in some circumstances, for example when the
discrepancy between the trauma and prior assumptions is too great,
emotional processing of trauma information becomes chronic.
Alternatively, emotional processing may be prematurely inhibited
because of sustained efforts to avoid the reactivation of highly
distressing information stored in VAM and SAM. In this situation,
Brewin et al. (1996) suggested, there may be no active emotional
processing (Rachman, 1980). However, SAM information should
still be accessible under certain circumstances, and the individual
hence remains vulnerable to delayed-onset PTSD when those
circumstances arise. Brewin et al. (1996) referred to these two
dysfunctional processing routes in tandem with successful processing as the three endpoints of emotional processing (p. 678).
Again, the evolutionary pedigree of DRT is reasonably transparent
here in terms of similarities between the three endpoints of processing and Horowitzs ideas on different courses of stress response as a function of different repertoires of defensive maneuvers (e.g., Horowitz, 1986).
Evaluation of DRT as an account of PTSD. DRTs evolutionary roots in earlier conceptualizations of PTSD are clear in that the
model incorporates a de facto network theory of the disorder (cf.
Foa et al., 1989) in its SAM representations. This provides the
model with all of the explanatory power of traditional network
approaches in terms of accounting for much of the core data of
PTSD as already discussed in the evaluation of network theory
sections above. In the conclusion to this earlier discussion, it was
suggested that stand-alone network theories offer a less complete
explanation of the transformation of meaning following trauma,
the processing of cognitions (including the mechanism of cognitive therapy), the mechanism of action of some pretrauma risk
factors, and the process by which appraisal-driven emotions might
be generated. In DRT, however, explanatory power has been
augmented by the inclusion of an explicit referential representational system in the form of VAMs that permits selective, intentional editing of trauma-related information. This provides a representational vehicle for the operation of cognitive therapy
techniques as well as more generic operations such as introspecting and thinking about the trauma and the generation of appraisaldriven emotions. However, as DRT does not explicitly include
representations of abstracted knowledge such as schemas (see
below), it is less convincing in its account of the transformation of
meaning following trauma and the operation of some pretrauma
risk factors such as previous psychiatric history.
Evaluation of DRT as a theory. By explicitly including two
types of mental representation, DRT provides the theorist with
greater range, as the explanatory power of both SAMs (de facto
networks) and VAMs (referential representations) is summated.
Furthermore, the evolutionary leap from a single type of representation to a dual-representation approach confers additive explanatory value that is derived from thinking about the interactions

COGNITIVE MODELS OF PTSD

between the two representational formats as well as the processing

that occurs within each format. DRT capitalizes on this in an
elegant manner. For example, in DRT, activation of SAM representations provides the raw material for the progressive development of VAM representations of the trauma. Reciprocally, intentional editing of VAM representations allows the traumatized
individual to titrate SAM activation during the recovery process.
As well as additive explanatory value arising simply from the
interaction of representations of different types within a theory
such as DRT, there is the potential for further additive value when
these different types of representation have the same referent (in
this case, the trauma). For example, the VAM representation may
incorporate information about individuals thoughts, feelings, and
actions surrounding the trauma that is contradictory to the information represented in SAMS. Such experienced discrepancies are
a common feature of PTSD (and indeed of emotional disorder),
and the ability to model them is an advantage of DRT. This also
opens the door to the possibility that treatment interventions directed at either type of representation are able to bring about
change in the other type of representation as a function of changes
in the pattern of interaction across representations. However, despite capitalizing on the advantages of interactions between SAMs
and VAMs, DRT is relatively silent on the question of exactly how
VAMs and SAMs might speak to each otherthe interaction of
components problem.
If one thinks of DRT as a development of associative network
theory (SAMs) where one of the types of networked representationsverbal referential meaning (VAMs) has been separated
off and elaborated, it begs the question as to why other forms of
networked representation have not received the same treatment in
the model. For example, visual images of past events that can be
consciously retrieved and edited seem to involve a separate mental
system (Rubin & Greenberg, 1998), and such images are clearly
present as components in the SAM network. Why not therefore
have a representational format for accessible visual memories?
As already noted, this issue is perhaps even more pertinent when
one considers the sort of abstracted meaning that is traditionally
represented by schemas. Again, the question is begged as to why
there is not a separate explicit representational system in DRT that
subserves abstracted meaning. At first glance this may seem a
somewhat misguided question to pose of DRT. After all, the work
of the schema theorists discussed earlier (e.g., Horowitz, 1986;
Janoff-Bulman, 1992) is clearly evident in the discussion of DRT
(Brewin et al., 1996). Nevertheless, despite extensive reference to
such abstracted knowledge in Brewin et al. (1996), it is unclear
how higher order models and assumptions about the world and the
self might actually be represented in the fabric of the theory. Are
these just one part of the VAM system? If so, then is it really true
to say that the contents of such models are verbally accessible in
their entirety? Furthermore, exactly how does the integration of
VAM information concerning the trauma into preexisting higher
order meaning structures take place? This seems to be a case in
which important aspects of the PTSD presentation are included in
the theoretical narrative without having an explicit representational
vehicle to sustain them (the number of components problem). As
I indicated earlier, this means that DRT struggles slightly to
provide a convincing account of aspects of PTSD that rely on

241

carefully articulated components that code generic meaning, such

as pretrauma factors and the transformation of meaning.
In principle, the greater representational detail in DRT, as compared to earlier unirepresentational theories, should be reflected in
greater specificity in the theory. To this end, it is clear that DRT
has stimulated interesting and important research designed to
assess the validity of dual representations in PTSD (see Brewin &
Holmes, 2003). For example, in an impressive study by Holmes,
Brewin, and Hennessy (2004), participants were presented with a
traumatic film clip and were given various concurrent cognitive
tasks to carry out while the film was presented. In one condition,
participants processed concurrent verbal information, and in another condition they processed concurrent visuospatial information. The rationale was that concurrent verbal processing should
disrupt the laying down of VAM representations about the film,
whereas concurrent visuospatial processing should compromise
SAM representations. The dependent variable was the number of
intrusions over the next week as assessed by self-report using
diaries. The hypothesis was that intrusions should be reduced in
the visuospatial condition (relative to a control condition), reflecting impoverished SAMs, and increased in the verbal condition,
reflecting impoverished VAMs, that would thereby not inhibit
SAM activity. The data confirmed these hypotheses.
It is indeed possible to interpret these data as supportive of the
two types of mental representations espoused in DRT, in terms of
different concurrent tasks differentially disrupting the laying down
of SAMs and VAMs. However, the data are equally consistent
with, for example, associative network theory, in which the network consists of stimulus, response, and meaning elements. Here,
different concurrent tasks would lead to a change in relative
density of such elements in the newly formed network, and this
would be reflected by the ease with which the network was
situationally activated, leading to intrusions. A relative lack of
stimulus elements (in the visuospatial condition) would lead to
fewer intrusions. A relative lack of (verbal) response and meaning
elements would reduce the number of points of contact between
the network and the existing autobiographical database, thereby
slowing the integration of the two and leading to more persistent
intrusive experiences.
However, it is important to make a distinction here between two
types of what one might call prospective utilitythe utility of a
theory as a tool for thinking and for the generation of ideas versus
its utility to make specific and unique empirical predictions. The
reality is that it is unlikely that a study such as that of Holmes et
al. (2004) would have been conducted without the impetus of the
ideas in DRT. Such a study certainly does not naturally emerge
from a consideration of network theory. In this sense, then, DRT
is a useful theoretical tool for generating research (and also clinical
interventions), even if the detailed predictions that it makes could
in principle be derived from other theories.

Ehlers and Clarks (2000) Cognitive Model of the

Maintenance of PTSD
Ehlers and Clark (2000) proposed a cognitive model that focuses on the maintenance of PTSD. Primary aims of the model are
to provide a theoretical context for the development of a new
cognitive behavioral treatment package for PTSD (Ehlers et al.,

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DALGLEISH

2003; Gillespie, Duffy, Hackmann, & Clark, 2002) and a theoretical framework within which to accommodate the burgeoning
literature on the importance of cognitions in PTSD (Dunmore et
al., 1997, 1999, 2001; Ehlers, Clark, et al., 1998; Ehlers et al.,
2000; Ehlers & Steil, 1995; Steil & Ehlers, 2000). The basic
components of the model are illustrated in Figure 3.
The central component of the model, as is clear from Figure 3,
is the notion of current threat. The argument is as follows. Posttraumatic stress reactions revolve around an event that is in the
chronological past. Consequently, the threat to the individual
posed by the reality of the event is also in the past. Therefore, to
understand how PTSD persists it is essential to conceptualize how
the past experience of a traumatic event can lead to a persisting
sense of threat about the present and the future. Ehlers and Clark
(2000) proposed that two key aspects of the model (see Figure 3)
contribute to the sense of current and future threat in PTSD: (a)
individual differences in the appraisal of the traumatic event and/or
its sequelae and (b) individual differences in the nature of the
memory representation of the traumatic event, in particular how
that representation is integrated with other episodic information in
long-term memory.
By highlighting a key role for appraisal processes in their model,
Ehlers and Clark (2000) have drawn on a strong tradition in
cognitive theorizing about emotions (see Scherer, 1999; Scherer,
Schorr, & Johnstone, 2001, for reviews) and emotional disorders
(e.g., Beck, 1976). Appraisals are essentially cognitive interpretations of information about the world or the self. The main tenet of
appraisals as they relate to emotion is that certain types of appraisal lead to the generation of certain types of emotion. Thus,
appraisals of perceived threat or danger lead to fear, appraisals of

loss lead to sadness, and so on (Scherer, 1999). In the Ehlers and

Clark model, therefore, it is the existence of appraisals of ongoing
threat or danger that is critical to PTSD maintenance (see Figure 3)
because, usually, the dominant emotion in PTSD is fear. Ehlers
and Clark (2000) provided several illustrations, such as interpreting the fact that the trauma happened at all in terms of the
appraisals that nowhere is safe or the next disaster will strike
soon (p. 322) or interpreting the existence of reexperiencing
symptoms such as flashbacks in terms of the appraisals Im going
mad or Ill never get over this (p. 322). By emphasizing a role
for cognitive processes in this way, the Ehlers and Clark model (as
with DRT) emphasizes the importance of being able to manipulate
and interrogate referential representations concerning the trauma.
The second component of the model that contributes to a sense
of ongoing threat is a function of individual differences in the
nature of traumatic memories. Ehlers and Clark (2000) argued that
memories for traumatic events are poorly integrated into the existing autobiographical memory database. This often makes intentional recall of traumatic memories difficult and leads to the
existence of poor narrative accounts of the traumatic event. In
addition to a lack of integration with other autobiographical material, traumatic memories are viewed as being internally cohesive
in the model such that representations of the various stimulus
elements involved in the traumatic event are strongly connected
(stimulusstimulus connections), and the representational relationship between those stimulus elements and the individuals responses at the time of the trauma are also strong (stimulus
response connections). This means that when the individual
encounters any stimulus related to the original trauma, however
tangential that relationship, the potential for intrusive reexperienc-

Figure 3. A schematic diagram of the Ehlers and Clark (2000) cognitive theory of posttraumatic stress disorder
(PTSD). Reprinted from Behaviour Research and Therapy, 38, A. Ehlers and D. M. Clark, A Cognitive Model
of Posttraumatic Stress Disorder, pp. 319 345, Copyright 2000, with permission from Elsevier.

COGNITIVE MODELS OF PTSD

ing of the traumatic memory is high. The nature of traumatic

memories is, furthermore, a function of the way information is
processed at the time of the trauma (e.g., Halligan, Michael, Clark,
& Ehlers, 2003). In particular, Ehlers and Clark drew on a distinction between data-driven (predominantly sensory) and conceptually driven (meaning-based) processing. The evolution of this
conceptualization of traumatic memory representations in the
Ehlers and Clark model from associative network theory (e.g., Foa
et al., 1989) and SAMs (and VAMs) in DRT (Brewin et al., 1996)
is clear and, indeed, is acknowledged in their article (Ehlers &
Clark, 2000).
Presenting a conceptualization of the processes underlying a
sense of current threat in PTSD is only one of the aims of the
Ehlers and Clark (2000) model. Arguably, a more important aspect
of the model is the presentation of a typology of cognitive and
behavioral responses to the ongoing sense of threat. These responses, in the short term, have the potential to ameliorate the
sense of threat; in the long term they act as a block to cognitive
change and thereby serve to maintain PTSD. The range of these
responses consists of the avoidance symptoms of PTSD combined
with other cognitions and behaviors that serve to confirm the
negative appraisals that the individual makes of the trauma and its
sequelae.13 For example, victims of trauma may avoid anything
that leads to strong affect because they have appraised that they are
unable to cope with strong emotions. Although this potentially
offers some protection in the short term, in the long term it
prevents individuals from learning that they can indeed cope with
surges of affect (Ehlers & Clark, 2000). The Ehlers and Clark
model provides a very strong account of the cognitive therapy
process in the treatment of PTSD, generating interesting research
ideas that have been rewarded by empirical data (Dunmore et al.,
1997, 1999, 2001; Ehlers, Clark, et al., 1998; Ehlers et al., 2000;
Ehlers & Steil, 1995; Steil & Ehlers, 2000) and providing the
framework for a new form of PTSD treatment (Ehlers et al., 2003;
Gillespie et al., 2002).
Evaluation of the Ehlers and Clark (2000) theory as an account
of PTSD. As with Brewin et al.s (1996) DRT, Ehlers and
Clarks (2000) theory harnesses the explanatory power exhibited
by traditional network approaches (e.g., Foa et al., 1989), this time
in the form of memory records rather than SAMs, and can therefore readily account for the core data of PTSD that network
theories can explain, as discussed in the evaluation of network
theory sections presented earlier. In the conclusion to this earlier
discussion, it was suggested that stand-alone network theories
offered a less complete explanation of the transformation of meaning following trauma; the processing of cognitions (including the
mechanism of cognitive therapy) the mechanism of action of some
pretrauma risk factors and the process by which appraisal-driven
emotions might be generated. In the Ehlers and Clark model, the
focus on a second explicit process that allows analysis (thoughts
and appraisals) about the trauma provides an effective framework
(though not a representational architecture; see Evaluation of the
Ehlers and Clark (2000) theory as a theory) for understanding the
mechanisms of both cognitive therapy following trauma and of
cognitions and appraisal-driven emotions more generally, thus
largely overcoming one of the main shortcomings of stand-alone
network theories. For these reasons, Ehlers and Clarks approach is
undoubtedly a powerful model of PTSD. However, as with DRT,

243

the lack of a fully articulated system for representing abstracted

meaning means that the Ehlers and Clark approach is less compelling in its account of the transformation of meaning following
trauma and in the operation of some pretrauma risk factors such as
previous psychiatric history. These issues are discussed further in
the next section.
Evaluation of the Ehlers and Clark (2000) theory as a theory.
In its architecture, Ehlers and Clarks (2000) model seems to go
beyond unirepresentational approaches to PTSD in that there are
two theoretical components that are implicated in the maintenance
of the disorder (see Figure 3). However, these two components of
the model that contribute to the sense of ongoing threat are
interesting in that one is a form of mental representation (traumatic
memories) whereas the other is a cognitive process (appraisal).
This is somewhat different to the previous theories that have been
discussed, in which the emphasis has been on aspects of mental
representation. By emphasizing the appraisal process, rather than
the representations underlying it, the Ehlers and Clark model
provides one of the more comprehensive accounts available of
how different types of cognition impact on the disorder and recovery from it. This provides a powerful context for the treatment
package, with its emphasis on cognitive therapy techniques, that
the model underpins (Ehlers et al., 2003).
An important upshot of this emphasis on the appraisal process,
however, is that there is no representational space that is uniquely
devoted to coding referential meaning; that is, there is nothing that
explicitly does the job of Brewin et al.s (1996) VAMs in DRT. It
seems that such representation of referential meaning is incorporated within the memory records in Ehlers and Clarks (2000)
theory as it is in traditional network theory. There are a number of
potential problems with such an approach (essentially, the number
of components problem) as preempted by Brewin et al. (1996).
Principally, it is not clear how to explain the fact that people can
talk about and interrogate their verbal (referential) memories of the
trauma, as required by the appraisal element of the model, without
feeling upset or seemingly activating any of the stimulus and
response elements that are linked to the referential information in
the same network or memory record. Similarly, at other times
certain reminders can trigger a range of emotions and images and
facts about the trauma that the person is unable to fully articulate.
This is essentially the difference between what authors such as
Beck call hot and cold cognitions (e.g., Beck & Emery, 1985;
Greenberg & Safran, 1984; Safran & Greenberg, 1982).
As with DRT, the proposal of two key components in the Ehlers
and Clark (2000) model provides additive explanatory value.
Ehlers and Clark emphasized three examples: First, the nature of
the information recalled from memory records will be congruent
with, and therefore a function of, the types of appraisals that are
being generated. Second, the experience of how the trauma and its
associated emotions are remembered determines the types of appraisal that are generated; for instance, amnesia may lead to
concern over the details of what happened or automatic emotions
13
As with the processes that contribute to the three endpoints of processing in DRT, these aspects of the model are directly descended from the
work of Horowitz (e.g., Horowitz, 1986) on different types of defensive
maneuver (see also Footnote 9).

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DALGLEISH

may lead to appraisals of being out of control. Third, persistent

negative appraisals will themselves become integrated into the
autobiographical knowledge base and become part of the memory
records.
As with DRT and associative network theory, the Ehlers and
Clark (2000) approach is relatively traumacentric. The nature of
any more generic representational structures (over and above specific memory records) is only briefly covered in their article
(Ehlers & Clark, 2000). For example, prior beliefs are bundled
together with a group of other pretrauma, trauma, and posttrauma
factors within one box in the model (see Figure 3). Ehlers and
Clark (2000) did propose that victims with prior negative beliefs
about themselves may see the trauma as a confirmation of these
beliefs and those with extremely positive beliefs may find that the
trauma shatters their trust in themselves or the world (p. 333).
These examples are theoretically revealing, and as with DRT, it
appears that implicit in the Ehlers and Clark model is the notion
that it is the nature of the relationship of the trauma to the
individuals preexisting beliefs about the self/world (in essence,
schemas) that determines the types of appraisals of current threat
that the individual generates.14 For example, an appraisal of Im
going mad in the light of flashback experiences only makes sense
in the context of a preexisting schema of being able to cope with
difficult events without experiencing extreme emotional reactions
and/or the context of a schema about the world that represents
flashback-like experiences as symptoms of madness. Similarly, a
number of the threats that Ehlers and Clark (2000) identified as
central to PTSD are generic (schematic) in nature: Threat can be
either external (e.g. the world is a more dangerous place) or, very
commonly, internal (e.g. a threat to ones view of oneself as a
capable/acceptable person who will be able to achieve important
life goals) (p. 320).
The lack of emphasis on the representation of generic meaning
in the model means that, as with DRT, the accounts that it offers
for the contribution of a number of pretrauma risk factors to the
course and severity of PTSD and of the transformation of meaning
are somewhat cursory. The fact that schemas, or analogous structures, are not center stage in the Ehlers and Clark (2000) approach
is perhaps surprising given the pedigree of the PTSD theory as a
member of a family of otherwise schema-based models that the
authors have used to model successfully other emotional disorders
such as panic disorder (Clark, 1986) and social phobia (Clark &
Wells, 1995).
As with DRT, the Ehlers and Clark (2000) model generally
lacks the specificity to make unique, testable empirical predictions.
For instance, although the model emphasizes the key role of
negative appraisals in the maintenance of PTSD, it generally does
not elucidate, a priori, that certain appraisals would be toxic and
others benign, nor how this might vary across individuals. Indeed,
such specificity would be difficult without a much fuller explication of the more generic-meaning representations that contextualize any appraisal that an individual would make. However, again
as with earlier theories, the Ehlers and Clark model has proved to
be a highly productive theoretical tool for the generation of research. In particular, a number of prototypical studies that have
identified key appraisals in the maintenance of disorder have
emerged as a direct result of the theory (e.g., Dunmore et al., 1997,

1999, 2001; Ehlers, Clark, et al., 1998; Ehlers et al., 2000; Ehlers
& Steil, 1995; Steil & Ehlers, 2000).
In summary, Ehlers and Clarks (2000) model is a variation on
the theme set by DRT (Brewin et al., 1996). Both are theories that
have a relatively traumacentric associative network at their core
(memory records and SAMs, respectively), and both have elaborated upon the representation and processing (VAMs and appraisals, respectively) of referential meaning. Finally, in both theories
abstracted meaning is clearly influential but remains unelaborated
in terms of the core components of the theoretical framework.

The Integrated Model of Foa and Colleagues

Foa and her colleagues have used their earlier fear network
model of PTSD (Foa et al., 1989; discussed in detail above) as the
foundation for the development of what I call the integrated model
of PTSD and what Brewin and Holmes (2003) have called emotion
processing theory. This model incorporates ideas from schemabased approaches about the representation of abstracted meaning,
thereby providing a theory with two explicit formats of representation that differs in emphasis from the work of Brewin et al.
(1996) and Ehlers and Clark (2000). These ideas are spread across
a series of chapters, articles, and a book (e.g., Foa & McNally,
1996; Foa & Meadows, 1998; Foa & Riggs, 1993; Foa & Rothbaum, 1998) and represent one of the more comprehensive cognitive theories of PTSD presently in the literature.
There are three core components to Foa and colleagues integrated model. Two of these are types of mental representation:
memory records (of the trauma and other pre- and posttrauma
events) and schemas. The third consists of the range of posttraumatic reactions of self and others. The nature of the components
and, crucially, the interaction between them are seen as determining the type and extent of posttrauma symptomatology. A schematic diagram of Foa and colleagues integrated model is presented in Figure 4.
Memory records of the trauma in the integrated model essentially include all of the elements of fear networks discussed in the
earlier work of Foa and Kozak (1986) and Foa et al. (1989; see
above and Figure 1). However, there are important extensions to
the basic concept that are proposed in the later publications. The
first of these extensions is a greater emphasis on the disorganized
nature of the memory records of traumatic experiences (Foa &
Riggs, 1993). Foa and Riggs (1993) argued that the coherence of
traumatic memory records is impoverished partly as a function of
disrupted and biased information processing at the time of trauma
(see Thrasher & Dalgleish, 1999; Williams, Watts, MacLeod, &
Mathews, 1997, for reviews). That is, trauma victims perception,
attention, and memory for information about the traumatic event
will be systematically biased by the extreme emotions experienced
at the time of the events occurrence. This then leads to disorganized or unbalanced memory records of the trauma. Foa, Molnar,
and Cashman (1995) put forward data in support of this argument.
They analyzed the therapy narratives of rape victims at the beginning and end of successful therapy. The findings showed that
14
Indeed, the citations in the article at this point refer to previous writing
on schema theory (e.g., Foa & Riggs, 1993; Janoff-Bulman, 1992).

COGNITIVE MODELS OF PTSD

245

Figure 4. A schematic diagram of Foa and colleagues integrated cognitive model of posttraumatic stress
disorder. Solid rectangles depict external events, and dashed-line rectangles depict representations in memory.
From Treating the Trauma of Rape: Cognitive Behavioral Therapy for PTSD (p. 78), by E. B. Foa and B. O.
Rothbaum, 1998, New York: Guilford Press. Copyright 1998 by The Guilford Press. Adapted with permission.

decrease in signs of disorganization in the narratives (such as

unfinished thoughts and repetitions) was correlated with symptom
improvement in the form of trauma-related anxiety. Similar findings were reported by Van Minnen, Wessel, Dijkstra, and Roelofs
(2002), in that reduction in the disorganization of thoughts in the
narrative was associated with reduced PTSD symptomatology
following treatment with exposure therapy. (However, see Halligan et al., 2003, for data that do not support a relationship between
measures of memory organization disorganization and PTSD
symptomatology.)
A second elaboration in the discussion of memory records
concerns the relative numbers of stimulus, response, and meaning
elements and their combinations in the representation of the
trauma (see also Figure 1). Foa and Rothbaum (1998) have proposed that trauma memories are often characterized by large
numbers of stimulus danger associations. That is, a lot of stimuli
in the world, even those only tangentially related to the trauma,
become associated with danger. Foa and colleagues (e.g., Foa and
Rothbaum, 1998) argued that the theoretical benefit of this characterization of the trauma memory record is that it goes some way
to explaining the generalized perception of danger that trauma
victims report. In this way abstracted meaning emerges (in the
form of schemas; see Figure 4) as a function of associative representations and the memory records in the integrated model are,
consequently, less traumacentric than in the original network theory (Foa et al., 1989).
Finally, Foa and Rothbaum (1998) proposed that trauma memories differ from other fear-related representations by virtue of the
diversity of the response elements that they contain. These response elements include physiological responses and a wide range
of behavioral responses that may have proved adaptive at the time
of the trauma (e.g., dissociation, numbing, screaming). If the
various behaviors associated with the trauma proved ineffectual at

the time of the event, then the diversity of response elements in the
trauma memory record may become associated with personal
ineffectiveness in the face of threat and thus may contribute to a
sense of the self as totally inept (Foa & Rothbaum, 1998, p. 81).
The second core representational structure (along with memory
records) in Foa and colleagues integrated model is that of schemas, as reviewed earlier. The basic strengths of this approach have
been presented in some detail above. Foa and colleagues provided
an extensive discussion of the role played by particular types of
schematic representation in the onset of posttraumatic stress (cf.
Horowitz, 1986, 1997; Janoff-Bulman, 1992). They concurred
with previous accounts in suggesting that traumatic experiences
can violate existing schematic knowledge, thus leading to a constellation of intrusion and avoidance symptoms. However, they
pointed out that such a conceptualization of the onset of posttraumatic stress requires that the content of pretrauma schemas is
highly discrepant from the implications of the traumatic event. For
example, Foa and Rothbaum (1998) proposed that a rape experience for a woman who, prior to the trauma, perceived herself to
be particularly invulnerable and strong may be highly disruptive to
her self-image (p. 79).
Foa and colleagues also highlighted the fact that not everybody
represents the world and the self schematically in ways that are
antithetical to the implications of a traumatic event. For many, the
pretrauma world is conceptualized as dangerous and unpredictable,
and/or the pretrauma self is conceptualized as incompetent and
worthless. To accommodate the evidence that suggests that pretrauma psychological and psychiatric disturbance that might reasonably be associated with negative views of the world and the self
is a vulnerability factor for the onset of PTSD (e.g., Brewin et al.,
2000; Burgess & Holmstrom, 1978; Ozer et al., 2003; Rothbaum
et al., 1992), Foa and Rothbaum (1998) argued that posttraumatic
stress develops because the trauma primes existing knowledge of

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DALGLEISH

oneself as extremely incompetent and the world as extremely

dangerous (p. 80). This is similar to some of the proposals made
by Horowitz (1986, 1997) in his discussion of how particular
constellations of negative schemata (pretrauma personality
types) and their pattern of interaction with defensive maneuvers
represent a vulnerability to traumatic stress.
Foa and colleagues writings on pretrauma schemas also echo
Janoff-Bulmans (e.g., Janoff-Bulman, 1992) emphasis on different types of pretrauma assumptions by drawing a distinction between representations about the self and representations about the
world. Foa and Rothbaum (1998) highlighted two repertoires of
schemas that are central in posttraumatic stress reactions (as opposed to the three clusters of Janoff-Bulman; e.g., Janoff-Bulman,
1989). The first repertoire centers on the world being entirely
dangerous and the second on the self being totally inept. Additionally, Foa and Rothbaum proposed that these two sets of schemas will inevitably interact. For example, If the world is indeed
utterly dangerous, then there is no way for the victim to protect
herself (i.e., the victim is incompetent). Similarly, the belief of
self-incompetence reinforces the view that the world is dangerous
(Foa & Rothbaum, 1998, p. 83).
The third strand of the integrated model is the range of posttrauma reactions of self and others. Individuals can interpret the
onset of posttraumatic symptoms as a sign of failure and weakness.
This is even more likely if the individuals pretrauma schemas are
centered on personal ineptness. Such an evaluation of ones response to trauma is likely to exacerbate a sense of personal
ineffectiveness and thereby maintain the posttraumatic state. The
types of self-generated posttrauma reactions that Foa and colleagues have identified mirror those discussed by Ehlers and Clark
(2000) in their typology of appraisals (see Foa, Ehlers, Clark,
Tolin, & Orsillo, 1999). Similarly, unsympathetic responses from
others such as being blaming or disbelieving will, according to Foa
and colleagues, reinforce the view that the world is untrustworthy
and dangerous as well as the sense of the self as incompetent.
Again, the result will be the maintenance of posttraumatic stress
symptomatology. This third element of the integrated model is a
crucial vehicle for cognitive therapeutic interventions in the treatment of posttraumatic stress.
Foa and colleagues discussion of how posttraumatic stress
reactions remit, either through exposure therapy or more spontaneously, implicates changes in both schemas and trauma memory
records. The process of change with respect to trauma memory
records includes those elements previously outlined in the Associative Network Theories section, though with some additional
points that are emphasized by Foa and Jaycox (1999) and Foa and
Rothbaum (1998). These additional points center on how exposure
therapy might serve to modify schema structures as well as memory records. First, exposure to the memory of the trauma in a safe
therapeutic setting facilitates the incorporation of safety information into the trauma memory record. Second, focusing on the
trauma memory over a number of treatment sessions helps the
victim to differentiate the trauma from other events. Foa and
colleagues argued that this helps the individual to consider the
trauma in isolation rather than as evidence for a dangerous world
or an incompetent self. Finally, the process of successful exposure
allows the trauma victim to change the meaning of PTSD symptoms from signs of personal ineptness to signs of mastery. Foa and

Rothbaum (1998) also proposed that the disorganized nature of

trauma memory records referred to above alters through repeated
exposure across therapy sessions as evidenced by the study by Foa,
Molnar, and Cashman (1995) discussed earlier.
Jaycox and Foa (1996) discussed how a number of factors can
impede successful treatment outcome using exposure. The first
factor that they highlighted focuses on how emotions such as anger
can prohibit recovery. Their discussion draws on the concepts of
the integrated model and proposes that the principal route by
which anger impedes emotional processing is by preventing the
individual from engaging with the fear and anxiety associated with
the trauma. Jaycox and Foa argued that shifting the focus of
therapy to work on the beliefs underlying the anger in a cognitive
fashion allows therapy to progress such that traditional exposure to
the trauma can be utilized in later sessions.
A second factor that Jaycox and Foa (1996) suggested impedes
emotional processing is the symptom of emotional numbing. They
argued that numbing represents a lack of activation of the fear
network underlying the trauma memory record, and they proposed
that without such activation and the concomitant experience of
anxiety, effective emotional processing cannot take place. Again
Jaycox and Foa proposed that a shift in therapeutic emphasis to
cognitively addressing the beliefs that prevent the experience and
expression of emotion is the way to overcome the barrier that
numbing presents to the successful resolution of PTSD.
The third impediment to emotional processing that Jaycox and
Foa (1996) highlighted is overwhelming anxiety. They argued that
such a level of emotion associated with the trauma actually confirms the pretherapy fears of losing control and of the anxiety
being overwhelming (Foa & Kozak, 1986) and can therefore be
highly detrimental with respect to successful treatment outcome.
Jaycox and Foa suggested a number of techniques for titrating the
exposure to the trauma, including focusing on details rather than
the whole and decentering from the trauma to some extent by, for
example, imagining projecting the image of the trauma onto a wall.
Cognitive therapy within the model seems essentially to be a
variation of the third component of posttrauma reactions of self
and others. As with Ehlers and Clarks (2000) approach, the
emphasis here is on mental process rather than mental representation (cf. VAMs in DRT; Brewin et al., 1996).
Evaluation of the integrated model as an account of PTSD. By
harnessing the explanatory power generated by both schema and
network representations, the integrated model of Foa and colleagues offers an impressive explanatory framework for understanding PTSD, accounting for most of the core data of the
disorder (as reviewed in the separate Evaluation of schema-based
theory as an account of PTSD and Evaluation of network theory as
an account of PTSD sections above). It represents a different
evolutionary trajectory (from the common origin of unirepresentational associative network and schema theories) than either DRT
(Brewin et al., 1996) or the model of Ehlers and Clark (2000). The
integrated model combines both of the single-format representations reviewed earlier into one framework, whereas DRT and
Ehlers and Clarks theory do not elaborate an explicit schematic
level of representation, concentrating instead on the elaboration of
referential meaning. The integrated model expands inventively on
the properties of both networks and schemas and the relationship
between them. By virtue of explicitly incorporating the strengths

COGNITIVE MODELS OF PTSD

of both the original associative network and schema models, the

integrated model provides a very robust account of onset, maintenance, and recovery with respect to the core posttraumatic stress
symptoms of intrusion, avoidance/numbing, and hyperarousal.
There is a clear articulation of how psychological treatments
promote recovery, especially prolonged exposure, and why they
are less efficacious for some individuals than others (see the earlier
Schema-Based Theories and Associative Network Theories sections). Networks and schemas are supplemented by a third component to the theory (in the form of posttrauma reactions of self
and others) concerned with processing and manipulating referential meaning (cf. Brewin et al., 1996; Ehlers & Clark, 2000). The
discussion of the dynamic interaction between pretrauma schemas,
memory records and posttrauma factors provides a coherent account of why some individuals develop posttraumatic stress while
others do not and emphasizes again the additive value of more than
one type of mental representation in modeling PTSD. The operation of pretrauma, trauma, and posttrauma factors is also addressed
in some detail.
Evaluation of the integrated model as a theory. One wrinkle in
the integrated model is that there is no proposed mental representation to underpin the third component of posttrauma reactions of
self and others as there is, for example, with VAMs in DRT. In
other words, there is no explicit mental representation of referential meaning. Instead, as with Ehlers and Clarks (2000) model,
such representations are included under the broader umbrella of
memory records. As already noted, this approach potentially runs
into problems when trying to account for discrepancies between
verbal accounts of the trauma and reexperiencing of the trauma in
other ways. For instance, Foa and colleagues argued that immediately following the trauma, the trauma memory record is extremely
disorganized, and the person is therefore unable to provide a clear
coherent narrative of the traumatic incident. However, through the
process of therapy, victims accounts of their traumas become
more coherent and cohesive (e.g., Foa, Molnar, & Cashman,
1995). The theoretical explanation provided for this process is that
the memory record is becoming more organized through the process of examining and reexamining the memory as therapy
progresses. In this explanation involuntary reexperiencing of the
trauma and intentional retrieval of the trauma memory are different
forms of access to the same representation. Consequently, the
organizational qualities of the one are mirrored by the other. This
contrasts with the line taken by Brewin et al. (1996) in DRT in
which two separable representational components fulfill this
function.
The principal question raised by Foa and colleagues explanation, however, concerns how the integrated model can account for
situations in which these two types of remembering seem to be
discrepant in their organizational coherence. For example, flashbacks and reliving experiences can sometimes represent extremely
cohesive accounts of the trauma in terms of level of detail and
temporal organization. However, in these circumstances, relatively
coherent flashbacks/reliving experiences can coexist with highly
disorganized and disjointed verbal narratives of the trauma (e.g.,
Foa, Molnar, & Cashman, 1995). Similarly, individuals can experience very disjointed sensory reexperiencing of the trauma and at
the same time be able to provide a coherent verbal narrative about
their experiences. Any theory that proposes different types of

247

representation for trauma information seems to have less trouble

explaining these types of data compared with a theory that includes
everything within one system, such as memory records. A similar
problem arises when one tries to model the difference between
so-called hot and cold cognitions using a single underlying representation, and this has been discussed in the section evaluating the
Ehlers and Clark (2000) model.
One of the more significant strengths of the integrated model is
the way in which the interaction between memory records and
schemas is presented. For example, clear statements are made
about how transformation of schematic meaning can arise out of a
critical mass of smaller changes at the memory record level of
representation. For example, the development of a schematic representation that the world is a dangerous place is seen as resulting
from a plethora of stimulus danger associations (Foa & Jaycox,
1999) in the memory records. Similarly, a representation of the self
as inept may result from a multitude of selfincompetence
response connections (Foa & Jaycox, 1999) in the memory record
representation. In this sense, the integrated model begins to speak
to the interaction of components problem.
Some aspects of the transformation of meaning during the
process of recovery are also principally driven by the relationship
between changes at the memory record and schematic levels. For
example, the therapeutic relationship and environment is seen as a
source of safety information that can be incorporated into the
memory records and thus dilute the picture that the world is a
dangerous place. Other aspects of the transformation of meaning
seem to suggest direct modification of representations at the schematic level. For example, the increasing ability to cope with the
symptoms of PTSD as therapy progresses is viewed as a means by
which the schema of self as inept can transform into the schema
of self as competent. Similarly, the continual reworking of the
traumatic memories helps develop the view that the trauma is a
unique occurrence and not necessarily representative of the world
as a whole. It is less explicit in the extant discussions of the model
how this direct schematic level change might occur.
The presentation of a clear hierarchical relationship between
schemas and memory records represents another critical step in the
evolution of theorizing in this domain. In essence, in the integrated
model, schemas represent summaries of the emergent properties of
the memory records. By doing so they achieve a sense of abstracted meaning not present at the level of memory record representations but at the expense of the loss of detail about individual
memories. In this sense, schemas can be thought of as higher level
representations that sit above memory records in the way, for
example, that sentence-level meaning sits above word-level meaning. This is different, say, than the relationship between VAMs and
SAMs in DRT, which are alternative representational formats at
the same level.
What are the advantages of levels (rather than just types or
formats) of mental representation within a theory of psychopathology? An illustrative example would be the case in which different
memory records seem to generate contradictory information. For
instance, the memory record of an uncontrollable trauma may
imply that the self is incompetent. However, there may be multiple
pretrauma memory records across a range of other situations that
code the self as competent. By integrating across these instances
(see Figure 4), and by weighting their importance, schemas can

248

DALGLEISH

code the discrepancy and confusion about self-competency that

arisesa common clinical picture in PTSD, as well as other
emotional disorders (Foa & Rothbaum, 1998).

The Schematic, Propositional, Analogue, and Associative

Representational Systems (SPAARS) Model
The SPAARS model (Dalgleish, 1999; Power & Dalgleish,
1997, 1999) was originally formulated as a model of normal,
everyday emotional experiences that could be applied to the domain of psychopathology, including PTSD. For this reason, it is
useful to broadly outline the basic model before reviewing its
application to PTSD.
The SPAARS approach to emotions comprises four explicit
levels/formats of mental representation (see Figure 5). There are
significant overlaps between these components and the representational constructs that have been used in the cognitive models of
PTSD described above. The schematic representational level is
broadly similar in conception to schemas and represents abstracted, generic knowledge. Propositional representations have
much in common with the verbally accessible representations
(VAMS) in DRT and represent referential meaning in verbal
form. The analogical representational system stores information
and memories in the form of visual, olfactory, auditory, gustatory,
body state, and proprioceptive images (Rubin & Greenberg,
1998) and codes nonverbal referential information to complement
the propositional system. Finally, associative representations are
similar to fear networks in that they represent the connectivity
between information represented in other ways.
As well as coding different types of information in memory
storage, the schematic, propositional, and analogical formats represent working memory spaces where active information can be
manipulated. In this way the different components in SPAARS
deal with both cognitive representation and process. At the propositional and analogical levels such processing comprises basic
manipulations of referential information such as thoughts or mental images. The schematic level is a higher level of mental repre-

Figure 5. A schematic diagram of the schematic, propositional, analogue,

and associative representational systems (SPAARS) architecture. From
Cognition and Emotion: From Order to Disorder (p. 178), by M. J. Power
and T. Dalgleish, 1997, Hove, England: Psychology Press. Copyright 1997
by Psychology Press. Reproduced with permission.

sentation that sits above the analogical and propositional level.

This is similar to the hierarchical relationship between pretrauma
schemas and memory records in Foa and colleagues integrated
model discussed in the previous section (see Figure 4). At the
schematic level, therefore, information from the lower level propositional and analogical representations can be integrated. For
example, the sounds, sights, smells (analogical representations),
and thought content (propositional representations) related to a
particular autobiographical event can be combined to give a coherent schematic sense of the whole experience over and above its
constituent parts. Similarly, discrepancies between different representations or between active information (in working memory)
and stored representations can be detected.
As in Foa and colleagues integrated model, SPAARS endeavors to
address some of the issues raised by the interaction of components
problem by discussing the systemic relationship of the different representational formats. This is done in two ways. The first concerns the
organizing role of schematic representations and the second, the
organizing role of emotions. At any given time within the model, it is
proposed that information in the schematic, propositional, and analogical representational domains is organized, activated, and inhibited
as a function of dominant (supraordinate) schematic representations
the schemas in place. For example, if a schema that broadly encoded
the concept of self as competent was supraordinate or in place,
stored congruent schematic, propositional, and analogical representations would be activated and competing representations inhibited. In
addition, new information streams would be filtered in favor of the
extraction of information congruent with the self-as-competent
schema (Beck et al., 1979). Via such processes information within the
system is assimilated into schematic representations which themselves accommodate to it (cf. Horowitz, 1986, 1997; Piaget, 1952). In
this way, then, schematic representations in SPAARS are about the
organization and filtering of both new and existing (represented)
information within the system.
Two routes to the generation of emotions are proposed within
the SPAARS framework. The first route is appraisal driven
(Scherer, 1999; Scherer et al., 2001), as in the model of Ehlers and
Clark (2000). Events and interpretations of events are appraised at
the schematic level of meaning with respect to the individuals
goals.15 For example, the emotion of fear is generated when there
is an appraisal of threat; that is, a schema is constructed in working
memory that represents the possible future interruption or noncompletion of a valued goal (see Scherer, 1999, for a discussion of
the relationship between particular patterns of appraisal and different emotions). The second proposed route to the generation of
emotion within SPAARS is an automatic route via associative
representations. This is essentially the same as the activation of the
fear network in Foa and colleagues theories discussed earlier.
Automatized emotions are generated in a way that does not involve
15
Essentially, goals are extensions of schematic representations at differing levels of abstraction (e.g., Ortony, Clore, & Collins, 1988). For a
thorough discussion of the relationship between mental representations
such as schemas and hierarchies of goals, see Carver and Scheier (1998).
Within SPAARS, the hierarchy of goals ranges from low-level, taskspecific subgoals to the highest level goal of maintaining the active pattern
of supraordinate schematic models.

COGNITIVE MODELS OF PTSD

appraisal with respect to the individuals goals at the time of the

events occurrence; rather, automatically generated emotions are a
function of the individuals emotional responses in the past and are
the result of biologically prepared, repeated, or overlearned
relationships.
Emotions, once generated, act as an organizing force within
SPAARS in that they can hijack the system to achieve a particular
end. Each emotion has a specific configural signature. That is, it is
associated with a particular configuration of activation and inhibition across the different levels/types of representation and their
associated cognitive processes. In SPAARS this is referred to as
the mode for that emotion (Power & Dalgleish, 1997). The function of emotion modes is to rapidly reconfigure the components of
the system to address the circumstances that originally led to the
generation of the emotion. For example, the emotion of fear would
be characterized by activation of threat-related information across
all of the representational domains and the potentiation of cognitive processes to maximize detection of any new information
pertinent to the original threat (Williams et al., 1997).
Individual differences in the pattern of emotion generation
within SPAARS are based on similar parameters to those described in some of the theories of PTSD already reviewed. The
first parameter comprises the organization and content of the
schematic representations (and the associated goal hierarchy), as
this is what drives appraisal-driven emotions. Schemas are classified into the domains of the world, self, or others. This is redolent
of Foa and colleagues (e.g., Foa & Rothbaum, 1998) binary
classification of schemas of world and self. Furthermore, as in the
schema model of Horowitz (e.g., Horowitz, 1991), different schemas can have the same referent. So, for example, there may be a
repertoire of positive schematic representations of the self as well
as a repertoire of negative schematic representations of the self.
One of the repertoires will be dominant/supraordinate (Horowitz,
1986, 1997) or act as the self in place (Dalgleish & Power, in
press) at any given time.
The second parameter relating to individual differences is the
nature of the systemic organizing principle across the representational components. This can range from predominantly involving
inhibition of both new and stored information incompatible with
supraordinate schemas to predominantly involving integration and
assimilation of that same information. This is similar to the classification of the different types of defensive maneuvers discussed
by Horowitz (e.g., Horowitz, 1997).
PTSD within SPAARS. Within SPAARS, a traumatic event
would lead to generation of intense appraisal-driven fear, helplessness, and horror as goals such as personal survival are threatened.
A range of other emotionsfor example, anger, sadness, shame,
guilt (e.g., Reynolds & Brewin, 1998)might also be experienced
as a function of relevant goal-related appraisals. Information about
the event and the individuals experience of and response to it will
be encoded in parallel as propositional, analogical, and schematic
representations. Associative representations linking aspects of the
event to each other and to their related emotions will be established. In this way trauma memories are distributed across different representational systems (as in DRT; Brewin et al., 1996)
rather than residing in one place.
Following a traumatic event (in the normative case), traumarelated information across different representations within

249

SPAARS is appraised as incompatible and as signaling a threat to

the supraordinate configuration of schematic models of the world
and of the self, as in traditional schema theory. Consequently,
processing resources are allocated to an assimilation process. Repeated appraisal of the incompatibility and threatening nature of
the trauma-related representations in memory generates aspects of
PTSD symptomatology. First, there is chronic low-level activation
of the fear mode, leading to an almost continuous state of being in
danger (the hyperarousal symptoms of PTSD). Second, information related to the trauma that is the object of such appraisals
intrudes, by virtue of its activated state, into consciousness in a
variety of ways ranging from intrusive thoughts to nightmares.
Such chronic activation of the fear mode and the related configuration of the system leads to a number of cognitive processing
biases for information related to the trauma (Buckley, Blanchard,
& Neill, 2000; Thrasher & Dalgleish, 1999). Consequently, any
cues that are related to the trauma are likely to be selectively
processed and to themselves activate the trauma-related information in memory, thereby further increasing the probability of
reexperiencing symptoms.
The trauma memory distributed across schematic, propositional,
and analogical representational systems within SPAARS is initially unassimilated into existing memory representations and
therefore can retain a high level of internal cohesion. This cohesion
is reflected in an associative representation of the trauma that links
the distributed representational elements together into a whole
essentially a traumacentric fear network. As a result, external cues
(that represent fragments of the traumatic experience) are able to
activate the entire trauma memory resulting in such phenomena as
flashbacks.
As PTSD symptomatology persists, further associative connections linking trauma-related information and emotions such as fear
become more strongly established as a function of the repetition of
this relationship during reexperiencing. Consequently, external or
internal trauma-related cues come to lead to the automatic generation of fear out of the blue. In addition to experiences of the
unwanted intrusion of information and emotions related to the
trauma, traumatized individuals are likely to intentionally interrogate their representations of the trauma, predominantly through the
editing and reediting of a propositional-level account of the event
or by reviewing analogical representations of their experience, for
example during imagery work. This process, in itself, both acts as
a powerful cue for further intrusions and provides the raw material
for further appraisal-driven emotions about what happened; for
example, reflecting on how helpless one felt during the trauma
leads to the generation of fear (Ehlers & Clark, 2000).16 As with
the other models, the magnitude of the intrusive phenomena leads
individuals to recruit a number of protective (avoidant) mechanisms and processes.
Five types of pretrauma personality and their implications for
the type and course of PTSD within SPAARS. Individual differences in the psychological response to trauma within SPAARS are
a function of, first, the content and configurations of pretrauma
16
This process is similar to the intentional editing of VAMs in DRT,
conscious appraisals in Ehlers and Clarks (2000) model, and the posttrauma reactions of self and others in Foas integrated model.

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DALGLEISH

supraordinate schemas and, second, the extent to which schema

supraordinacy is maintained by systemic inhibition or assimilation,
as discussed above (cf. Brewin et al., 1996; Horowitz, 1997). For
some individuals, the world may be schematically represented as
reasonably safe or the self, as reasonably invulnerable prior to the
traumawhat are termed balanced schematic representations. For
other individuals the world is schematically represented, de facto,
as completely safe and the self, as completely invulnerable prior to
the traumawhat Foa (e.g., Foa & Riggs, 1993) has termed
overvalued schematic representations and Elliott and Lassen
(1997) have called inflexible positive schemas. Finally, for other
individuals the world is represented as dangerous and unpredictable and/or the self as incompetent or vulnerable prior to the
traumathat is, negative pretrauma schematic representations of
the world and self (Beck et al., 1979; Elliott & Lassen, 1997).
With these three classes of supraordinate or in-place schemas
balanced, overvalued, and negativein three different domains
world, self, and otherwith two classes of system dynamic
assimilatory and inhibitorythere are myriad permutations within
SPAARS to represent pretrauma individual differences. Five of
these pretrauma personalities (cf. Horowitz, 1986, 1997) are
elaborated in the SPAARS model with respect to the course of
PTSD. The first (and normative) case involves balanced schematic
representations across all domains of the world, self, and others. In
such instances, there is usually an initial period of posttraumatic
symptomatology followed by gradual assimilation of traumarelated information into existing schematic representations within
weeks or months, either within therapy or within a social support
network (cf. Horowitz, 1986; Janoff-Bulman, 1992).
There are two proposed personality types for which supraordinate schematic representations are classed as overvalued. The first
case refers to individuals who may have led relatively predictable,
controllable, and safe lives in which things have rarely gone wrong
and goals have invariably been fulfilled; that is, the overvalued
schematic representations of self, world, and other might be a valid
reflection of the individuals experiencesvalid overvalued schemas. In the second case, overvalued schematic representations may
have been maintained through systemic inhibition of information
relating to negative experiences (Dalgleish, Mathews, & Wood,
1999). Shedler, Mayman, and Manis (1993) characterized individuals with this latter type of representation as having illusory
mental health (p. 1117). In individuals with such illusory overvalued schemas, the schema repertoire would include overvalued
supraordinate positive schemas and subordinate negative schemas
reflecting the unintegrated negative experiences from the individuals learning histories (cf. Beck et al., 1979; Dalgleish & Power,
in press).
Within SPAARS it is suggested that both of these classes of
overvalued schematic representations reflect vulnerability to distress following a traumatic event in different ways. For individuals
whose pretrauma experiences have been genuinely safe, controllable, and predictable, the proposal is that the traumatic event is
too discrepant from the pretrauma schemas to be readily assimilated. Consequently, such individuals are likely to be relatively
more at risk of suffering severe and chronic PTSD. In contrast, in
those cases in which overvalued supraordinate schemas have been
maintained by systemic inhibition of subordinate negative schemas, it is likely that inhibitory processes will continue to be

deployed more or less effectively when dealing with the new

trauma-related information. This is akin to Brewin et al.s (1996)
premature inhibition of emotional processing. Nevertheless, the
trauma-related information will become integrated with, and will
potentiate, the subordinate negative schemas. In such instances it is
proposed that acute PTSD reactions are less likely, though symptoms such as emotional numbing, psychogenic amnesia, selfmedication, psychosomatic problems, and dissociation may be
relatively highly prevalent (see also Brewin et al., 1996; Horowitz,
1997; Pennebaker, 1995). However, it is suggested that such cases
are characterized by vulnerability to delayed-onset PTSD when
either later life changes or the occurrence of situations similar to
the original trauma shift the dominance relationships of the schematic representations of self, world, and others such that negative
schemas become supraordinate (cf. Beck, 1976). Life events such
as these may be sufficient to overwhelm a system in which there
is already inhibition of information related to the previous
trauma.17
The fourth personality type concerns individuals who possess
negative (supraordinate) pretrauma schematic representations of
the world and self as a function of their life experiences. As
discussed by Foa and colleagues (e.g., Foa & Rothbaum, 1998),
these individuals are likely to experience wholesale confirmation
of their schemas by the trauma. Within SPAARS, the only predicted difference in their symptom presentation from that of the
other cases discussed already would be that there would be no
generation of reexperiencing symptoms as a function of a discrepancy between preexisting schematic representations and traumarelated information. However, reexperiencing symptoms as a function of multiple cueing would still occur, and related avoidance
and hyperarousal symptoms would still be present.
The final personality type involves individuals with negative
schematic representations of the world (a negative world in place)
but ostensibly positive (either balanced or overvalued) representations of the self. This is seen to reflect the schema profile of
many trauma victims from the military, the emergency services,
and other groups associated with chronically negative environments (e.g., Prager & Solomon, 1995). For such individuals,
negative representations of the world have considerable validity
and can be sustained as long as the representations of the self are
sufficiently positive to cope with the negative world. Within
SPAARS, it is proposed that PTSD often results following a break
down of such self-schemas rather than from experiencing a trauma
that is significantly worse than previous negative world experiences (e.g., Solomon et al., 1989).
Treatment of PTSD within SPAARS. The proposed processes
underlying treatment effects in the SPAARS model overlap with
those in the other theories discussed above. The main difference
involves the level of specification of the underlying mental representations. Cognitive therapy within SPAARS is seen to represent
the interrogation and manipulation of referential meaning in the
17
In some cases, supraordinate overvalued schemas may be maintained
in a more fragile way. Here, schema switching (Horowitz, 1986) or
vacillation (Elliott & Lassen, 1997) may occur as a direct result of the
trauma leading to acute PTSD as a function of acquired supraordinacy of
pretrauma negative schemas.

COGNITIVE MODELS OF PTSD

form of propositional (thoughts, beliefs, interpretations) and analogical (images, bodily sensations) representations. Also, comparison of different beliefs, thoughts, and so forth occurs at the
schematic level. This is another example (along with Foas integrated model) of the utility of a multilevel approach wherein
information from lower levels of the system can be compared at a
higher level of the system such that new meanings are generated.
Schematic and referential (propositional and analogical) representations are also important when considering exposure therapy.
As in the work of Foa and colleagues, exposure therapy is conceptualized as having two distinct components. First, extinction
across associative connections linking trauma-related stimuli and
fear-related responses occurs during the exposure process (see also
Footnote 11). Second, the experience of exposure provides new
information about what it feels like to encounter the trauma memory. This information can then be compared with any expectations
regarding this experience (Foa & Kozak, 1986). Within SPAARS,
such expectations are coded as propositional representations. As in
cognitive therapy, the process of comparison is carried out at the
schematic level of representation. Here, the discrepancy between
expectations (propositional representations) on the one hand and
the feelings generated by the exposure (analogical representations
of feeling states) on the other can be made. New meanings can then
be generatedfor example, that the exposure was not as bad as
expected (Foa & Kozak, 1986). These new meanings would then
be recoded as new expectations in the form of propositional
representations such that the next exposure session would be
easier.
The basic SPAARS framework also offers an explanation of
how the treatment of PTSD can promote the assimilation of trauma
memories into preexisting schematic representations of the self,
world, and others. The basic tenet is that the therapy context itself
acts as a proxy for world schemas of safety, predictability, controllability, and so forth, and the more stable the therapeutic
environment, the more this is the case. Accessing the trauma
memory within this therapeutic context, therefore, promotes the
construction of overarching schematic representations in which the
trauma experience is contextualized within a generally safe, controllable, and predictable world.
This idea that the therapy milieu potentially acts as a proxy for
the individuals pretrauma schematic representations of the world
is also important in the SPAARS account of some aspects of
treatment nonresponse in PTSD. The basic suggestion is that the
(hopefully positive) therapy environment can only act as a proxy
for representations of the world in those individuals for whom such
pretrauma schematic representations were reasonably positive (in
the terminology of the model, either balanced or overvalued). In
those individuals for whom the pretrauma schematic representation of the world was negative, there is necessarily a mismatch
between this schematic representation and the positive therapy
environment. The proposal within SPAARS is that this mismatch
increases the likelihood that exposure to the trauma memory will
become too stressful and even potentially toxic in the form of
retraumatization of the patient, as the buffering effects of potentiated (pretrauma) positive world schemas will be absent.
The second aspect of treatment nonresponse in PTSD that is the
focus of the SPAARS approach speaks to the data showing that the
presence of strong emotions such as anger, shame, and guilt are

251

potential indicators of poor prognosis (e.g., Jaycox & Foa, 1996).

The SPAARS model endeavors to account for this issue in two
different ways. The first is a comment on the temporal perspective
of different emotions surrounding a traumatic event. Fearthe
predominant emotion associated with traumais prospective. That
is, it is about something negative that might happen in the future.
Repeated exposure to a traumatic memory involving fear will
quickly reveal an absence of future threat, thus allowing the fear to
dissipate. In contrast, emotions such as anger, shame, and guilt are
retrospective. That is, they are about something negative that has
already happened. Repeated exposure to a traumatic memory involving these emotions is merely likely to accentuate what was
guilt-, shame- or anger-inducing about the original experience.
The second way in which SPAARS accounts for the contraindications for outcome of certain emotions in PTSD draws on the
basic tenet of cognitive therapy (Beck et al., 1979) that negative
thoughts and appraisals that lead to emotions are a function of
underlying schemas. The SPAARS account of PTSD raises the
possibility that some posttrauma negative appraisals (Ehlers &
Clark, 2000; Foa, Ehlers, et al., 1999) and emotions are actually a
function of pretrauma functional schematic representations rather
than dysfunctional schemas. The emotion of guilt is a good illustration of this possibility (e.g., Herman, 1992). Individuals who
report intense irrational guilt following a trauma may not be
experiencing an emotion congruent with dysfunctional schemas of
self-blame. Rather, the guilt may reflect functional pretrauma
schemas that include themes such as controllability of the world
and agency (see also Janoff-Bulman, 1992). In other words, feeling
guilty about things you could have done to prevent a negative
event may serve to consolidate and strengthen pretrauma schemas
that the world is a place in which there are things that you can do
to prevent negative events. In this type of analysis, some apparently negative interpretations and emotions following trauma may
be cognitively functional. Emotions and appraisals that are actually
functioning to strengthen and consolidate pretrauma functional
schemas may be predictive of poor treatment outcome if the
treatment process is partly focused on challenging those emotions
and appraisals and the outcome measures partly depend on reductions in those emotions and appraisals as a marker of response.
Evaluation of the SPAARS model as an account of PTSD. The
SPAARS model of PTSD combines the advantages of several of
the uni- and multirepresentational theories reviewed earlier by
incorporating referential, schematic, and associative network representations and can therefore account for the core data of PTSD
presented earlier (and as already outlined in the evaluation sections
discussing these earlier approaches). This is perhaps not surprising. Proliferation of representational formats in this way always
increases the explanatory power of a theory as an account of a set
of phenomena. However, such proliferation has costs for that
theory as a theory.
Evaluation of the SPAARS model as a theory. By detailing
explicit representational substrates for abstracted, generic meaning
(schemas), referential meaning (propositional and analogical representations), and connectivity between constructs (associative
representations), SPAARS goes some way to overcoming the
number of components problem that it has been argued is inherent
in some of the other approaches reviewed. SPAARS also attempts
to address some of the issues posed by the interaction of compo-

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DALGLEISH

nents problem. There is clear discussion of the systemic organizing

principles within the model. Furthermore, the relationship across
levels whereby the higher (schematic) level conflates across information at lower (propositional and analogical) levels is discussed.
However, other aspects of the interaction of components problem remain unresolved within SPAARSspecifically, how information seemingly coded very differently, such as schematic representations and analogical representations, can move
interchangeably between different representational formats. For
this reason, as with all of the other models reviewed, SPAARS still
struggles to address the specificity problem in a truly convincing
manner and, again as with the earlier multirepresentational approaches, the predictive utility of SPAARS is greatest as a tool for
the generation of research ideas rather than of theory-specific
predictions.
Another problem that arises as a result of the numerous representations within SPAARS is the complexity of the final product.
SPAARS is clearly less accessible than, for example, DRT, which
includes two explicit representational formats relatively closely
focused on the trauma itself. It is a genuine issue whether, in
practical terms, the increased explanatory power that the extra
representations deliver in SPAARS is simply negated by the fact
that the model is so much harder to understand and use both in
terms of research and clinical work. This is an issue that is returned
to in the General Discussion.

General Discussion
The Advantages and Disadvantages of a
Multirepresentational Approach to PTSD
In the central section of this article I have described and critically evaluated a number of cognitive theories of PTSD. This
analysis has focused on three core representational components
that have dominated cognitive theorizing in this area: schematic
representations that are particularly strong at modeling abstracted
knowledge of the self and world, referential representations that
are particularly strong at modeling specific verbal and nonverbal
(e.g., images) information concerning the trauma and its consequences, and associative networks that are particularly strong at
modeling the connectivity between information represented in
different ways. Each of these cognitive components, considered in
isolation, has strengths and weaknesses (and these have been
reviewed in the evaluation sections earlier in the article). For this
reason, cognitive theorizing in PTSD has evolved beyond models
that rely almost entirely on any one of these cognitive components
to models that combine two or more of the components in what
have been termed multirepresentational theories of the disorder,
and such theories represent the current state of the art in cognitive
approaches to PTSD. Combining cognitive components in this way
can clearly confer an explanatory advantage, but such an approach
is also not without its costs.
The most obvious advantage is that the explanatory power of a
given multirepresentational theory is at least as good as the sum of
the separate degrees of explanatory power generated by each
representational construct within the theorywhat I term summated explanatory value. Thus, a theory such as Foa and colleagues integrated model (e.g., Foa & Rothbaum, 1998) that

combines schemas with an associative network will be able to

explain all of the things that stand-alone schema and network
theories can account for separately. However, including more than
a single aspect or format of representation also confers what I call
additive explanatory value in at least three main ways.
The first way is the interaction of information across different
types of representation such that they reciprocally activate or
inhibit each other. For example, the generation of automatic fear in
PTSD might lead to appraisals that the stress response was uncontrollable; these appraisals would in turn potentiate negative schemas about, for instance, lack of agency. Similarly, a reduction in
automatically generated fear reactions through extinction during
an exposure session might precipitate a reappraisal of the individuals symptomatology such that it was seen as controllable as
opposed to uncontrollable (Foa & Kozak, 1986). This, again, may
then impact on schematic representations of agency and so on.
The second form of additive value arises from the conscious
experience of the same object in different waysfor example, the
notion that traumatic memories can be experienced as sensorily
rich visual images and flashbacks and/or as verbally encoded
narratives (e.g., Brewin, 2001; Brewin et al., 1996). Such different
types of experience can either be in some form of synchrony,
where, for instance, the narrative and visual image versions of the
trauma have broadly the same content and associated emotions, or
they can be somewhat discrepant. For instance, the narrative
account may contain a different version of events to those included
in a set of visual memories, and one version only may be associated with strong affect.
The third form of additive value reflects the fact that some
representations sit at a higher level than others. So, schematic
representations of a trauma will sit above referential representations and such schemas will therefore represent abstracted meaning that is not present at the lower level. In the example above, in
which verbal referential representations (narratives) and visual
referential representations (images/visual flashbacks) contained
differing content, the higher level schematic representations would
code this discrepancy. This representation of discrepancy and its
associated feeling states of unease and confusion reflects a level of
meaning that is therefore abstracted from a conflation of both sets
of lower level referential representations. The combination of
summated and additive explanatory value ensures that multirepresentational theories of PTSD are powerful tools for thinking in that
they provide fertile ground for the generation of clinical and
research ideas that would not readily emerge from the use of
simpler models of the disorder as an analytic tool.
However, despite these advantages over unirepresentational theories, cognitive theories of PTSD that have embraced more than
one core cognitive component are not without their problems. The
first such is their undoubted complexity. Such complexity can
prove aversive to some of those who would seek to use the theories
in clinical and research settings. A second problem, as I have
iterated throughout this review, is the need to be explicit about
exactly how the different representations interactthe interaction
of components problem. If the theorist sidesteps this constraint
then it is possible to proliferate levels and types of representation
unchecked, thereby continually adding degrees of freedom and
hence explanatory power to the theory. Using such an approach, it
would surprise nobody that multirepresentational theories could

COGNITIVE MODELS OF PTSD

outperform unirepresentational ones. However, such theoretical

cavalierism is a bit like having a sophisticated set of computer
components central processing unit, monitor, keyboard, mouse,
printer, Web cam, Internet access, DVD drive, scanner, and so
onwith no way for any of the components to communicate with
each other. It is clear that such a set up would have the potential
to do things that a simpler set up would not be able to do.
However, without a way of successfully getting the components to
interact, this potential cannot be realized. All of the multirepresentational theories of PTSD critiqued in the present review are
guilty to a greater or lesser degree of finessing this interaction of
components problem.
Finally, the relative silence in the extant theories regarding the
interaction of components and, indeed, the theoretical mechanics
more generally means that the theories are not usually able to
speak very clearly to specific patterns of existing data nor to
generate unique (theory-specific), testable predictions. In other
words, although the prospective utility of the current theories is
good as tools for thinking, it is less satisfactory in terms of specific
empirical predictions.

The Current Status of Cognitive Theories of PTSD

As they stand, then, multirepresentational theories of PTSD
have some strengths and some weaknesses. However, such an
evaluation is little more than bean counting unless one considers
the research/clinical environment in which the theories have
evolved to exist. Theories have different stakeholders. For some
stakeholders, what I have identified as the weaknesses of multirepresentational theorizing may be largely irrelevant, whereas for
others they may be so central that the theories will not be adopted.
In terms of cognitive theories of PTSD (and indeed of psychopathology) two classes of stakeholder are particularly important: the
clinician/clinical researcher and the basic scientist/pure theorist.
In clinician/clinical researcher stakeholder terms, a theory of
PTSD should offer an account of the symptoms of the disorder and
their treatment, should have prospective utility in terms of being a
tool for thinking about how treatments might be developed and/or
why existing treatments might fail for some individuals, and ideally, should be reducible to a digestible form that can be discussed
with patients to provide them with a rationale for the treatment that
is being carried out. By such metrics, current cognitive theories of
PTSD are generally keeping abreast (and may even be slightly
ahead) of market demands. They are able to provide strong accounts of the presentation of the disorder and of existing treatment
effects. Furthermore, they generate numerous ideas about the development of PTSD treatment that remain to be tested. Finally,
they can be generally distilled into forms that clinicians and
patients with PTSD can understand. In a sense, then, current
cognitive theories of PTSD are well evolved for the clinical/
clinical research environment in which they are predominantly
utilized. Thus, one could argue that although current multirepresentational theories of PTSD have weaknesses, these weaknesses
are largely academic for the clinician/clinical researcher at the
present time. However, I propose that multirepresentational theorizing in PTSD has now reached a critical juncture in its evolution.
If the complexity of theorizing continues any further such that the

253

resulting models become more abstruse then clinicians/clinical

researchers are likely to lose enthusiasm for the approach.
The basic science/pure theorist stakeholder has an altogether
different set of expectations of a theory than the clinician/clinical
researcher. For the pure theorist, issues such as the interaction of
components problem are critical. Similarly, pure theorists are more
motivated to broaden theoretical horizons from disorder-specific,
microtheoretical approaches (such as those that focus only on
PTSD) to what might be called macrotheory (Barnard, May, Duke,
& Duce, 2000) comprising models that embrace various psychopathological and nonpsychopathological presentations. After all,
PTSD is only one of a range of reactions to a trauma. Presentations
of depression, personality change, adjustment disorders, dissociative disorders, other anxiety disorders, substance abuse, and even
psychosis are also common (Joseph et al., 1997). Because of this
variety of psychopathology with the same ostensible etiological
agent, as well as the presence of large numbers of traumatized
individuals with no apparent psychological problems posttrauma,
it is increasingly difficult for the pure theorist to defend any theory
that speaks only to PTSD, rather than to more general issues of
stress response.18 Similarly, for the basic empirical scientist it is
not really enough that the current theories are useful conceptual
tools for generating ideas and interventions. Ideally, the theories
should offer up unique, tightly prescribed, and falsifiable empirical
predictions. For the pure theorist/basic scientist, then, the limitations inherent in current theories of PTSD are frustrating, and there
is some enthusiasm for developing more complex, highly specified
models.
There is a dilemma here then. Whereas the theoretical advances
that would satisfy the pure theorist/basic scientist are undoubtedly
worthy, for the clinician/researcher stakeholder they are likely to
make the theory less wieldy and ultimately render it redundant in
the applied domain. This is not just a problem for the future of
cognitive theorizing in PTSD but potentially for psychopathology
more generally.

PTSD as a Paradigm Case

To what extent is the evolution of multirepresentational cognitive theorizing in PTSD a paradigm case for the way cognitive
theory is developing in the rest of psychopathology? If this view is
to have any mileage, then two broad conditions must be met. First,
it needs to be shown that the three core cognitive components that
18
This point is further emphasized when one shifts attention to other
levels of theoretical explanation such as the neurobiological. Increasingly,
theorizing at a functional psychological level of explanation needs to be
constrained by the data from neurobiology. The data on the neurobiology
of emotional disorders seems to indicate that various forms of psychopathology, including PTSD, as well as normal emotional reactions are all
broadly subserved by the same neural circuitsprincipally those involving
orbitofrontal cortex, anterior cingulate, amygdala, thalamus, hippocampus,
and perirhinal cortex (e.g., Lawrence & Grasby, 2001). The message from
the neuroscience literature therefore seems to be that normal emotions and
so-called emotional disorders must be accommodated largely within the
same neurobiological framework. There seems to be little support, at the
level of the brain, for multiple microtheories of specific disorders or of
normal emotions that have little overlap with each other.

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DALGLEISH

have emerged from the PTSD literature (propositional representations, schemas, and associative networks) have a wider utility.
Second, it needs to be demonstrated that combining the three
components, as compared with a unirepresentational approach, has
the potential to convey worthwhile advantages in cognitive theorizing in domains of psychopathology other than PTSD that outweigh any associated costs.
Associative networks have an enduring theoretical currency in
the domain of emotional disorders. The work cited in relation to
PTSD (e.g., Foa et al., 1989) arose out of a more general cognitive
theory of fear responses in anxiety (including specific phobias,
agoraphobia, and obsessive compulsive disorder) proposed by
Foa and Kozak (1986). This in turn has its origins in behavioral
learning theory (e.g., Mowrer, 1960) approaches to fear conditioning. With respect to other mood disorders, the pioneering work of
Gordon Bower (e.g., Bower, 1981) on associative models of everyday emotional experience has been influential, especially in the
modeling of depression (see Forgas, 1999, for a review). Network
approaches to emotion and psychopathology have been granted a
new lease on life by the growing interest in affective neuroscience.
A plethora of research studies has provided robust empirical support for various associative routes to emotion (see Rolls, 2000, for
a review), and these have led to the concomitant development of
influential neurobiological theories with a strong associative component (see, e.g., Izard, 1993; LeDoux, 1990).
Similarly, theories revolving around referential and schematic
representations have recently been the zeitgeist in psychopathology research at the cognitive level of explanation. The influence
and spread of cognitive therapy as an effective treatment for a
range of disorders (Beck, 1976; Beck & Emery, 1985; Beck &
Freeman, 1990; Beck et al., 1979) has carried with it the notion
that manipulating and interrogating visual and verbal forms of
referential meaning is a route to positive mental health outcomes.
Furthermore, cognitive therapy as a clinical intervention is underwritten by a range of credible theories that have both schematic
and referential representations at their heart (see Gotlib & Abramson, 1999; Teasdale & Barnard, 1993, for discussions). This theorizing in the clinical domain is allied with a strong focus on
appraisal and schema theories in the psychology literature on
normal, everyday emotions (e.g., Scherer et al., 2001).
It seems clear then that the different representations used by
PTSD theorists have a reasonable pedigree as stand-alone theories
in other domains of psychopathology. However, to what extent is
it the case that other forms of psychopathology resemble PTSD in
being more adequately modeled by multirepresentational (as opposed to unirepresentational) cognitive theories?19 To address this
question, I shall consider two forms of psychopathology at different ends of a hypothetical continuum of clinical complexity: major
depressive disorder and specific phobia (American Psychiatric
Association, 1994).
The development of cognitive models of depression (major
depressive disorder; American Psychiatric Association, 1994) is a
clear corollary to the evolution of cognitive theorizing in PTSD.
As was the case with PTSD, early cognitive approaches to depression reflected the predominance of schema theory and network
theory in the modeling of emotion and psychopathology. Associative network accounts of sad mood (e.g., Bower, 1981) were
extended to account for some of the data on depression. Mean-

while, in the clinical domain, the cognitive therapy model of

depression of Beck and colleagues (e.g., Beck et al., 1979), with its
key role for dysfunctional negative schemas and the manipulation
and interrogation of referential meaning, was developed. In addition, theories of depression that rested on patterns of negative
appraisals of events in the world were being proposed (Abramson,
Seligman, & Teasdale, 1978). During the 1980s and 1990s, these
various approaches to modeling depression came in for criticism
for not offering a complete account of the disorder (see Forgas,
1999; Power & Dalgleish, 1997; Teasdale, 1999b; Teasdale &
Barnard, 1993; Williams et al., 1997, for discussions). These
theoretical debates within the literature and the emergence of more
and more data in the domain of cognition and emotion revealing
the psychological complexity of the disorder led to the development of a multilevel theory of depressioninteracting cognitive
subsystems (ICS; Barnard, 1985; Barnard & Teasdale, 1991; Teasdale & Barnard, 1993). ICS is a theory with nine explicit formats
of representation that provides a robust account of the data of
depression and potentially models normal everyday emotions and
other emotional disorders (e.g., Barnard, 2003). As with PTSD,
depression is a complex disorder that appears to reflect a set of
psychological problems that resists adequate explanation by theories that focus on one explicit cognitive component or format of
mental representation. As far as depression is concerned, then,
there is a compelling argument that the development of cognitive
theorizing in PTSD would be a suitable paradigm case.
Individuals suffering from a specific phobia (American Psychiatric Association, 1994) experience strong fear reactions to discrete stimuli such as spiders, snakes, heights and so on. Here it
seems that a single-level associative network model can provide
the most parsimonious account of the core aspects of the disorder,
with fear being automatically generated via associative connections following exposure to the phobic stimulus (see Emmelkamp,
1982). However, the proponent of multirepresentational approaches to psychopathology might argue that, even in the case of
specific phobias, closer inspection of the research and clinical data
reveals a suitably complex picture. For example, the DSMIV
requires that the person recognizes that the [phobic] fear is
excessive or unreasonable (American Psychiatric Association,
1994, p. 410). It is not immediately clear how a single-level
associative network is able to model a representation of the discrepancy between beliefs about the phobic object and the experience of automatic fear reactions to that object. Furthermore, as
with the case of PTSD, cognitive appraisals concerning the experience of fear following exposure to the phobic object, such as the
fear being uncontrollable, are likely to exacerbate the disorder by
maintaining avoidance (Foa & Kozak, 1986). The flip side of this
is that the phobic individuals experiencethat fear actually subsides during prolonged exposure rather than spiraling out of controlpromotes recovery through between-sessions habituation
(Foa & Kozak, 1986). However, the more parsimonious theorist
might respond by highlighting the fact that the essence of phobic
19
Theoretical developments in modeling normal emotions have evolved
in a similar manner with multilevel theories being proposed by Leventhal
and Scherer (1987), Johnson and Multhaup (1992), and Power and Dalgleish (1997).

COGNITIVE MODELS OF PTSD

reactions is the intense fear to a discrete object and that overcomplicating ones theory to account for the metaemotional beliefs
about the phobic reaction is a process of ever diminishing returns
if, for example, one hopes to use the theory in any kind of applied
way in the clinic.
It seems that for a given psychopathological presentation, there
will exist a trade-off between the increased explanatory power
allied with increased complexity and compromised clinical utility
of multirepresentational models versus the reduced explanatory
power, allied with increased simplicity and clinical utility of, for
example, unirepresentational approaches. How this trade-off is
resolved will depend on the aims and needs of the person using the
theory. For example, for the clinician/clinical researcher stakeholder identified earlier, a fully articulated multirepresentational
model of specific phobias might have more disadvantages than
advantages. For this stakeholder, in fact, the complexity of a theory
can be fully determined by the complexity of the core clinical
phenomena that are to be explained. Consequently, along the
hypothetical dimension of clinical complexity alluded to earlier,
one would expect generation of bespoke theories that have one,
two, three, etcetera cognitive components/representations as the
problem space demands. Indeed, this is a fair summary of the way
things are heading, with a plethora of localized, customized theories of psychopathology, with different theoretical semantics, reflecting the clinical complexity of the phenomena that they are
seeking to model. On this point, it is important to note that
relatively few psychopathological presentations can be convincingly modeled by a theory involving just a single cognitive component. In this sense, specific phobias with their highly circumscribed pathogenic stimulus and restricted range of symptom
response are somewhat atypical (American Psychiatric Association, 1994).

A Tentative Theoretical Agenda

In the above The Current Status of Cognitive Theories of PTSD
section it was proposed that there was currently a dilemma to be
resolved. In a theory-as-theory sense, it seemed clear that cognitive
theorizing should continue to negotiate two important moves: first,
from unirepresentational theory to properly formulated multirepresentational theory and second, from microtheory (about discrete
psychopathologies) to macrotheory, which endeavors to speak to a
broader database (Barnard et al., 2000). However, it was suggested
that such progress at the level of formal theorizing runs the risk of
alienating those clinicians and researchers who have the potential
to apply the theory to real-world problems. On this basis, I proposed that current theory development in PTSD was at a crossroads, where the theories have reached a level of complexity which
remains accessible but where any increase in the complexity of the
theories is likely to deter clinicians and clinical researchers from
using them. In the previous section, PTSD as a Paradigm Case, I
suggested that such a dilemma needs to be resolved for cognitive
theorizing in psychopathology across the board. I proposed that
clinical researchers and clinicians would tolerate theoretical complexity to the extent that it is seen to be necessary to understand the
clinical conditions that they are working with. In the event that a
given theory is, by this metric, too complex, a simpler theory will
be developed or adopted. The upshot of this is that across the

255

theoretical literature on cognitive approaches to psychopathology

there now exists a range of customized models with varying
numbers of cognitive components as a function of the perceived
complexity of different clinical conditions. The problem with this
state of affairs, of course, is that it is impeding the evolution of the
type of cognitive macrotheory of psychopathology that the pure
theorist stakeholder is invested in.
To resolve this dilemma, Barnard (1991) has suggested that
theory development needs to proceed on two interrelated levels.
There needs to be a substrate of deep theory that includes a focus
on what I have called theory as a theory aims and that pushes
theorizing along the road from micro- to macrotheory. At the same
time, if such theorizing is going to avoid the trap of being no more
than an academic exercise, distilled versions of the same theory
that can be applied by clinicians and researchers also need to be
developed. These more localized satellite theories would have
the formal, deep theory as a common point of origin.
There are two ways in which one can approach such an exercise.
The first is top down and involves generating a general theoretical
framework that can serve as a common starting point for (a)
localized theories that use limited aspects of the framework and (b)
a program of deep, formal theorizing that seeks to flesh out the
framework in terms of theoretical mechanics. This has been the
approach behind both the SPAARS framework and the ICS model.
SPAARS was developed as a general framework for understanding
emotion and emotional disorder and aspects of the SPAARS
framework have been applied to a range of psychopathology from
phobias to depression (Power & Dalgleish, 1997). However, there
has to date been little development of the SPAARS approach in
terms of deep, formal theorizing. The ICS framework has been
distilled into an accessible form that has provided impetus for the
development of a new treatment of depressionmindfulnessbased cognitive therapy (e.g., Teasdale, 1999a). In addition, deep
theorizing about ICS has resulted in a formal mathematical model
of aspects of the theory using process algebra (Barnard & Bowman, 2003).
This top-down approach to cognitive theory development, although currently partially successful, might nevertheless seem to
be somewhat naive. The sociology of academic endeavor is such
that theorists can find more rewards within the system if they (a)
shun deep theory altogether and concentrate on more popularist
localized approaches and (b) develop their own theory, as opposed
to devoting their precious research and thinking time to somebody
elses theoretical ideas. However, even within this system, the
enduring popularity of a set of ideas is related to the extent to
which those ideas genuinely model the problem space. This provides an opportunity for another bottom-up way of resolving the
dilemma by using firmly established localized models as a starting
point from which to develop deep theory that conflates across
families of such models, as opposed to the other way round. A
good example of this concerns the family of theories under the
umbrella of cognitive therapy. Here, a host of localized theories,
applying to different types of psychopathologies and differing
quite considerably in their specific architectures (e.g., Beck &
Emery, 1985; Beck et al., 1979; Clark, 1986; Clark & Wells, 1995;
Ehlers & Clark, 2000; Fairburn, Shafran, & Cooper, 1999; Garety,
Kuipers, Fowler, Freeman, & Bebbington, 2001; Salkovskis,
1986), have considerable currency in the applied clinical/research

256

DALGLEISH

domain. Furthermore, they have common theoretical ground in

their subscription to constructs such as schemas, automatic
thoughts, and biases in information processing. This common
ground is therefore a potentially fertile place for deep theory to
flourish. Such deep theory would knit the localized theories together and could proceed on its own terms to address the more
formal theoretical challenges that may be of less immediate concern to the applied clinician or researcher.
Either of these directions presents a considerable challenge to
the clinical/academic community working in the domain of psychopathology. However, the problems do not end here. Another
central part of the theoretical manifesto should be to relate
psychological-level theories to theories at other levels of explanation. Our increased understanding of the role of neurobiological
(see also Footnote 18) and sociocultural factors in the onset and
maintenance of psychopathology means that purely cognitive (and
indeed, purely psychological) theories must now have a limited
shelf life (see Brewin, 2001; Dalgleish & Morant, 2001, for some
discussion of these issues with respect to PTSD). Introducing
additional levels of explanation into the theoretical mix will have
advantages in that it will serve to constrain the final product. For
not only will a theory have to fly with respect to the psychological
data but also with respect to, say, the data from neuroscience. This
will increase the specificity and hence the predictive power of the
resulting theory. The main problem however is that theories at
different levels of explanation rely on theoretical constructs and
semantics that rarely translate to other levels in a readily identifiable way. So, for example, schemas (at the psychological level of
explanation) may not map in any straightforward manner onto any
neurobiological construct. This means that theories that seek to
bridge levels of explanation will need to include theoretical arguments concerning the exact relationship between constructs at
level of Explanation A to constructs at level of Explanation B. It
seems certain that this will almost never be a case of simple
one-to-one mapping (Barnard et al., 2000). What is also clear is
that theoretical integration across levels of explanation will be
much harder if at any given level there is little theoretical consensus. This strengthens the case for an agenda in which cognitive
theorizing about psychopathology seeks to capitalize on any common ground that exists, as outlined above.

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Received April 25, 2002

Revision received June 30, 2003
Accepted September 3, 2003 !