Cognitive Therapy & Extinction
According to the previous analysis a traumatic event may be considered to be an overwhelming aversive sensory condition that evokes intense negative emotion (e.g. fear, helplessness, and horror), autonomic arousal (e.g. increases in heart rate, blood pressure, and skin conductance), and sensation of perceived pain. With time and developing consolidation processes an internal representation of the trauma in the brain emerges. When undeclared in a coherent narrative, this internal representation may become trapped in consolidation processes. When PTSD trauma memory is internalized in this way, it embodies the external and internal cues that had been present and associated with the traumatic event. Evoked intense autonomic arousal, visceral sensation, negative emotion and negative implicit appraisals of self in interaction and associated emotion may get trapped into brain and central nervous system, when it is not verbally declared into a coherent trauma narrative embedded with personal meaning.
Since the 1990s cognitive-behavioral therapies like Edna Foa’s Prolonged Exposure (PE) have been successfully treating PTSD. The Prolonged Exposure (PE) method directly encourages expression of trauma-related experience. Due to its empirical testing, transparency and documented ability at modulating trauma-related amnesia this section will focus and elaborate on its methods and findings and how it links with extinction.
The PE method is an in vivo exposure method that was adapted from cognitive-behavioral therapy’s (CBT) flooding and desensitization. Traditional CBT’s exposure therapy encourages the phobic client to confront, relive, desensitize, and reduce anxiety to an innocuous fear-producing object, condition, or situation (Foa & Kozak, 1986). Repetitive reexposure to the CS-CR as such, promotes symptom relief through extinction-mediated habituation. PE also helps clients to confront and face distressing responses to overwhelming traumatic events reminiscent of initial responses to life threatening experiences, nonsexual and sexual assaults, combat and/or torture and natural disasters, etc. (Foa, Cashman, Jaycox, & Perry, 1997; Meadows & Foa, 1998). As noted earlier initially experienced traumas and responses to those traumas can become internally represented in consolidation processes and trapped. Cognitive therapy for PTSD with PE may help to release this memory in the following manner.
During PE the client is instructed to internally generate and recall sensory details of an assault “as if it were happening now.” This helps to temporarily pair the internal representation of the trauma with the existing phase of consolidation. Attending to traumatic material (CS) in this way helps to generate personally meaningful emotions (CR), like those linked with emotions of fear, anxiety, helplessness, and loss of sense of trust in oneself and others (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999a; Foa, Riggs, Massie, & Yarczower, 1995a). As the inner representations (CS) of and generated response (CR) to this memory are retrieved and declared (by MTL structures) in PE therapy, this (CS) memory can be unpaired and released from fear-related consolidation neural structures. Examining the relationship between the CR and CS as such may well involve “learning about the relationships between internal affective states and external stimuli…” functions suggesting hippocampal-amygdala involvement and interactions (White & McDonald, 2002, p. 138). Relational analysis of assigning personal meaning to traumatic events may allow for the later expression of medial prefrontal structures that are involved in declared emotion and extinction. This may also allow expression of significant symptom reduction treatment effects of decreases in patient-rated indices for overall depressed mood, anxiety, and trauma related distress, e.g. numbing, dissociation, avoidance, intrusive reexperiencing of emotionally laden trauma memory, etc. (Foa, Molnar, & Cashman, 1995b; Jaycox, Foa, & Morral, 1998). The patient is also better able to develop, retrieve and declare a personally meaningful, temporally organized, and chronologically sequenced, complete trauma script, which is not only reflective of what, where and how the traumatic event happened, but also able to reference the impact of the traumatic event on the psychological and personal self (Foa et al., 1995a; van Minnen, Wessel, Dijkstra, & Roelofs, 2002). This may suggest greater mPFC involvement (Macrae, Moran, Heatherton, Banfield, & Kelley, 2004; Vogt, Berger, & Derbyshire, 2003). The client is better able to resolve feelings of self-blame (Foa & Rauch, 2004) and, with the help of cognitive restructuring’s problem solving analysis, the emotion of guilt (Resick, Nishith, Weaver, Astin, & Feuer, 2002). Finally declared traumatic memory also reduces the implicit need for sustained compensatory behavioral adaptations for active thought suppression and behavioral and cognitive avoidance of trauma reminders (Foa, Dancu, Hembree, Jaycox, Meadows, & Street, 1997; Bryant, Sackville, Dany, Moulds, & Gutherie, 1999). PE reductions in state anxiety and depression are sustained at three, six, twelve, and forty-eight month follow-up periods (Foa et al., 1999b; Bryant, Moulds, & Nixon, 2003). In fact a trend for PE’s treatment effects of reduced symptom severity, avoidance of traumatic subject matter, unwanted intrusion of troubling sensory images and distressing emotions, and arousal continues into a three-month follow-up period (Foa, Rothbaum, Riggs, & Murdock, 1991). This suggests continued post-treatment CS-unpairing and associated consolidation activity well after therapy was concluded.
References
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