Behavioural models of PTSD

The avoidance of situations and objects directly associated with the trauma and marked physiological arousal in the presence of feared stimuli are major PTSD symptoms. A similar picture is seen in specific phobias. However, PTSD has certain dissociative symptoms not present in phobias such as psychogenic amnesia, re-experiencing symptoms such as flashbacks and nightmares, and heightened levels of general arousal. The model of PTSD described by Foy et a! (1987) considers the symptoms to be a conditioned response to a traumatic event. Everyday objects and situations become associated with the traumatic event These conditioned stimuli then provoke the same response as the original trauma. The response persists for a number of reasons, including the sufferer's avoidance of stimuli associated with recall of the traumatic memory and avoidance of the memory. This reduces the opportunity for exposure to the emotions provoked by the memory, leading to continued symptoms. Although PTSD, by definition, must involve exposure to an aversive event, most phobics do not report such an experience at the start of their problems. More recent explanations for the develop ment, selectivity and appearance of phobias at certain ages have included Gray's (1987) ideas on maturation and innateness. If the route of acquisition of specific phobias is different from those fears acquired traumatically then the out come of treatments successfully used to treat phobias may be less confidently predicted in PTSD. Graded, prolonged and repeated in-vivo exposure to feared cues has been shown to be the most reliable way of eliminating phobias (Marks, 1981). It is at first attractive to use such techniques with an apparently similar condition such as PTSD. However, should the differences between PTSD and phobias outlined above outweigh the similarities then they may not be appropriate. Alternatively, in-vivo exposure may not be sufficient for the treatment of PTSD. Although in-vivo exposure is generally regarded as more effective than imaginal exposure with phobics and obsessives (e.g. Marks, 1981) there are some situations where real-life exposure is not practical nor possible and imaginal exposure is then used. Four cases of PTSD, and their treatment, are described. Symptoms respondeddifferently to two behavioural approaches. In-vivo exposure was effective for phobic anxiety while imaginal exposure improved dysphorla and some phobic symptoms. Audio-taped imaginal exposure may be Important as part of treatment. British Journal of Psychiatry (1991), 158, 836—840