Unraveling the Mind

A Deep Dive into the Cognitive Aspects of Trauma

by Anabel Massabki and Lana Kamareddine

Exposure to trauma can have an enduring impact on an individual’s mental well-being. In the Cognitive Science Department at Operation Twelve, we are interested in researching how trauma, or an emotional response to a disturbing event, can impact our cognition, thinking, perception, reasoning, and judgment (American Psychological Association [APA], 2023). While many people experience at least one traumatic event in their lives, only six to ten percent are diagnosed with Post-Traumatic Stress Disorder (PTSD) (Beierl et al., 2020; Stevens & Jovanovic, 2018). PTSD is a condition characterized by persistent symptoms occurring after an individual is exposed to a traumatic event, such as threatened or actual death, sexual violence, war and political turmoil, or natural disasters (DSM-5, APA, 2013). Some of the symptoms encountered include the repeated unwanted re-experiencing of the traumatic event, avoidance of stimuli that act as a reminder of the incident, hyperarousal, and emotional numbing (Ehlers & Clark, 2000). Individuals may start displaying symptoms of PTSD even several years after initial exposure to the incident (Qureshi et al., 2011). 

The emotional experience of trauma may have a persistent cognitive impact. Previous research has shown that symptoms of PTSD may result in changes to various cognitive processes. Such processes include memory, attentional and executive functioning, psychomotor speed, and planning (Hayes et al., 2012; Blanchette et al., 2019). It is important to note that individuals diagnosed with PTSD are more likely to show signs of cognitive impairment compared to those who are not diagnosed, but were exposed to a traumatic incident (Qureshi et al., 2011). They also have a reduced capacity for attention in comparison to individuals who were previously exposed to a traumatic event, but have not developed PTSD. This conveys an association between the severity of symptoms and the extent of cognitive impairment. 

Over the years, numerous cognitive researchers have proposed cognitive frameworks that attempt to explain trauma. Ehlers & Clark (2000) proposed a cognitive model pertaining to PTSD which suggests that the disorder becomes persistent when people interpret the trauma in a manner that fosters a serious ongoing sense of threat. This indicates that individuals continue to feel like they are in danger, even when they are no longer in immediate danger. This continuous sense of threat emerges due to two factors, with one being negative appraisals of the trauma and/or its sequelae (Ehlers & Clark, 2000). For instance, a negative appraisal could pertain to thoughts such as feeling permanently damaged or blaming oneself for the traumatic incident. The second factor is the disruption of an individual’s autobiographical memory, resulting in individual differences in the nature of the memory. When a person undergoes a traumatic incident, this can disturb the way in which they recall and process memories regarding their own life. Therefore, the way in which the individual evaluates and processes the incident can influence the severity and extent of the PTSD symptoms portrayed (Mitchell et al., 2017). 

Positive or adaptive appraisals would result in healthier coping mechanisms. However, an individual may develop dysfunctional cognitive strategies due to trying to control the feelings brought by negative thoughts (Ehlers & Clark, 2000). Maladaptive cognitive strategies include thought suppression, ruminative or repetitive thoughts concerning the incident and its consequences, and trying to not actively think about the event. For instance, a person might start going to bed at a late time or wake up extremely early in order to decrease their likelihood of having nightmares about the traumatic event. This portrays an attempt to control some of the symptoms they might face; however, this might increase the frequency of intrusions and emotions pertaining to the trauma. Furthermore, Beierl et al. (2019) aimed to understand the cognitive pathways leading from the initial trauma to persistent PTSD symptoms by examining the cognitive model proposed by Ehlers & Clark (2000) in survivors of assault or road traffic collisions. The findings portrayed that negative appraisals of the traumatic incident and/or its sequelae and resulting maladaptive cognitive coping mechanisms at one month predicted the severity of the symptoms six months after the trauma occurred. Therefore, addressing the negative cognitive patterns and implementing effective coping mechanisms during the early stages would potentially mitigate long-term PTSD symptom severity. 

One of the main avenues for treatment of both acute and chronic PTSD is through Cognitive Behavioral Therapy (CBT), which addresses the thinking patterns of patients, like maladaptive and negative thoughts, or overgeneralizations for bad outcomes, in an effort to maintain healthier and more balanced thought processes (APA-CBT, 2017). In essence, an individual’s behavior and emotional state are heavily affected by the way they think about and perceive the world around them, and thus CBT can help pave the way for a healthier outlook and well-being (Kar, 2011). Several studies have indicated positive preventative effects of CBT regarding PTSD symptoms, with participants recounting fewer and less intense avoidance, intrusive, and depressive symptoms, even in post-study follow-ups (Kar, 2011). One of the most effective treatments in CBT for PTSD is prolonged exposure; rather than reinforcing their fears and avoiding thoughts or memories about the traumatic event they experienced, prolonged exposure urges patients to gradually approach their trauma-related memories through both imagined and in vivo conditions (APA-PE, 2017). One study has demonstrated that significant reductions in PTSD symptoms, namely reductions in negative thinking, were correlated with prolonged exposure therapy (Zalta et al., 2014). PTSD symptom severity and negative cognitions about the self also have been shown to decrease with prolonged exposure therapy (Kumpala et al., 2017). 

In more recent studies, a form of CBT with a Trauma-Focused specifier (TF-CBT) has been shown to be effective. In a pilot clinical trial done with Iraqi women who had war-related trauma, results indicated that a culturally adapted TF-CBT treatment reduced PTSD, depression, anxiety, and stress symptoms, and increased quality of life one month after the trial, in comparison to a waitlist control (Zemestani et al., 2023). Interestingly, the cultural adaptations including the use of vernacular language and incorporation of folk tales, indicated that TF-CBT could be effective in countries with lower incomes (Zemestani et al., 2023). While Cognitive Behavioral Therapy does not necessarily work for everyone, the literature clearly demonstrates its effectiveness in treating PTSD. 

The cognitive theory of trauma provides us with a valuable framework for understanding how our minds may respond to adverse, traumatic events as well as their interplay with cognitive processes. Therefore, acknowledging the relationship between cognition and trauma allows researchers to develop and utilize increasingly effective interventions that target the main issue at hand. Cognitive Behavioral Therapy and its specific treatments have been shown to reduce symptoms of PTSD and improve overall well-being for patients. As trauma is intrinsically tied to our thinking and emotional processes, the focus that CBT brings to recognizing our negative or irrational thoughts has proven to be effective. However, as indicated by Zemestani et al (2023), much of the research regarding PTSD has been conducted in Western countries. Our current research at Operation Twelve aims to address gaps within this discourse, as we are eager to contribute to a better understanding of trauma responses and processing from a non-Western perspective. 

References

• APA. (2023). APA Dictionary of Psychology. Apa.org. https://dictionary.apa.org/cognition
• APA. (2023). APA Dictionary of Psychology. Apa.org. https://dictionary.apa.org/trauma
• American Psychological Association. (2014). Exhibit 1.3-4, DSM-5 Diagnostic Criteria for PTSD. Nih.gov; Substance Abuse and Mental Health Services Administration (US). https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part1_ch3.box16/
• American Psychological Association. (2017). Prolonged Exposure (PE). Https://Www.apa.org. https://www.apa.org/ptsd-guideline/treatments/prolonged-exposure
• American Psychological Association. (2017). Cognitive Behavioral Therapy (CBT). Https://www.apa.org. https://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy
• Beierl, E. T., Böllinghaus, I., Clark, D. M., Glucksman, E., & Ehlers, A. (2019). Cognitive paths from trauma to posttraumatic stress disorder: a prospective study of Ehlers and Clark’s model in survivors of assaults or road traffic collisions. Psychological medicine, 50(13), 2172–2181. https://doi.org/10.1017/S0033291719002253
• Blanchette, I., Rutembesa, E., Habimana, E., & Caparos, S. (2019). Long-term cognitive correlates of exposure to trauma: Evidence from Rwanda. Psychological Trauma: Theory, Research, Practice, and Policy, 11(2), 147–155. https://doi.org/10.1037/tra0000388
• Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour research and therapy, 38(4), 319–345. https://doi.org/10.1016/s0005-7967(99)00123-0
• Hayes, J. P., VanElzakker, M. B., & Shin, L. M. (2012). Emotion and cognition interactions in PTSD: a review of neurocognitive and neuroimaging studies. Frontiers in Integrative Neuroscience, 6. https://doi.org/10.3389/fnint.2012.00089
• Kar, N. (2011). Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatric Disease and Treatment, 167–167. https://doi.org/10.2147/ndt.s10389
• Kumpula, M. J., Pentel, K. Z., Foa, E. B., LeBlanc, N. J., Bui, E., McSweeney, L. B., Knowles, K. A., Bosley, H. G., Simon, N. M., & Rauch, S. (2017). Temporal Sequencing of Change in Posttraumatic Cognitions and PTSD Symptom Reduction During Prolonged Exposure Therapy. Behavior Therapy, 48(2), 156–165. https://doi.org/10.1016/j.beth.2016.02.008
• Mitchell, R., Brennan, K., Curran, D., Hanna, D., & Dyer, K. F. (2017). A Meta-Analysis of the Association Between Appraisals of Trauma and Posttraumatic Stress in Children and Adolescents. Journal of traumatic stress, 30(1), 88–93. https://doi.org/10.1002/jts.22157
• Stevens, J. S., & Jovanovic, T. (2018). Role of social cognition in post-traumatic stress disorder: A review and meta-analysis. Genes, brain, and behavior, 18(1), e12518. https://doi.org/10.1111/gbb.12518
• Qureshi, S. U., Long, M. E., Bradshaw, M. R., Pyne, J. M., Magruder, K. M., Kimbrell, T., Hudson, T. J., Jawaid, A., Schulz, P. E., & Kunik, M. E. (2011). Does PTSD impair cognition beyond the effect of trauma?. The Journal of neuropsychiatry and clinical neurosciences, 23(1), 16-28. https://neuro.psychiatryonline.org/doi/10.1176/jnp.23.1.jnp16
• Zalta, A. K., Gillihan, S. J., Fisher, A. J., Mintz, J., McLean, C. P., Yehuda, R., & Foa, E. B. (2014). Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure. Journal of Consulting and Clinical Psychology, 82(1), 171–175. https://doi.org/10.1037/a0034735 Zemestani, M., Mohammed, A. F., Ismail, A. A., & Vujanovic, A. A. (2022). A Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women. Behavior Therapy. https://doi.org/10.1016/j.beth.2022.01.009