PTSD Formulation

Post-traumatic stress disorder (PTSD) is a common reaction to traumatic events where someone was exposed to actual or threatened death, serious injury, or sexual violence. A large-scale review gave the lifetime incidence of PTSD as 8.3% (Kilpatrick et al, 2013). 

Symptoms of PTSD include:

• Intrusion symptoms. These can be characterized by: recurrent, involuntary, intrusive and distressing memories of the traumatic events; recurrent distressing dreams where the content or affect of the dream are related to the traumatic event; dissociative reactions where it feels as though the traumatic events are recurring in the present moment (flashbacks); and intense or prolonged physiological distress at exposure to reminders of the trauma.
• Avoidance symptoms. These might include avoiding or trying to avoid: distressing memories, thoughts, or feelings about the traumatic events; external reminders that trigger distressing memories, thoughts, or feelings about the trauma (e.g., people, places, conversations, activities, objects, or situations).
• Negative alterations in cognitions and mood associated with the traumatic events. These can include: being unable to remember an important aspect of the traumatic events; persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent, distorted understanding of the cause or consequences of the traumatic events that lead the individual to blame themselves or others; persistent strong negative emotions (e.g. fear, anger, guilt, shame); diminished interest or participation in activities; feeling detached from others; and feeling unable to experience positive emotions.
• Marked alterations in arousal and reactivity. These should begin or worsen after the traumatic event, and may include: irritable behavior and angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, and problems falling or staying asleep.

Notably, people suffering from PTSD feel a current sense of imminent danger. Ehlers & Clark’s model of PTSD, published in 2000, provides a comprehensive cognitive behavioral formulation of PTSD. They describe PTSD as a ‘puzzle’: if anxiety is thought to be the result of believing there is an impending threat, why does anxiety persist in PTSD, even though the worst has already happened? Their model makes a number of important proposals which explain why a sense of current threat is maintained in people suffering from PTSD:

• Memories. Memories of the traumatic event may have particular properties including: involuntary recall, fragmentation, high levels of vividness, sensory and emotional re- experiencing, and experiencing the memories as if they were happening right now (nowness). These properties have the effect of creating a sense of current threat.
• Appraisals. A person’s appraisals (the meaning they make of events) also create a sense of serious current threat. Appraisals may be of the trauma, or consequences of the trauma. Perceived threats might concern the world (e.g “the world is dangerous”) or the self (e.g., “I’m responsible”, “I’m broken”).
• Behaviors. Feeling a sense of serious current threat leads naturally to coping behaviors. These responses can be cognitive or behavioral, and notably include avoidance. These strategies are well-intended, but prevent cognitive change (i.e. prevent change in threat appraisals) and thus prevent recovery.

Trauma-focused cognitive therapy for PTSD (CT-PTSD) is an empirically supported treatment for PTSD derived from the Ehlers and Clark model. It is recommended as a first-line treatment in international clinical guidelines (APA, 2017; ISTSS, 2019; NICE, 2018). Wild et al. (2020) describe how CT-PTSD has three aims:

1. To elaborate and update the trauma memory in order to reduce re-experiencing symptoms.
2. To modify negative appraisals.
3. To change strategies that maintain the patient’s sense of threat and simultaneously help them to reclaim activities in their life that promote a sense of worth and meaning.

A crucial early intervention in CT-PTSD is to help clients to develop their own idiosyncratic version of the model, and helping clients to understand how the components of the model maintain their PTSD. This PTSD Formulation worksheet is designed to facilitate this process. It uses client-friendly language, and simplifies elements of the full Ehlers and Clark model in order to help clients to understand what they need at the early stages of therapy. Elements of the formulation that therapists are advised to help their clients work through include:

• My trauma. A space to elicit a very brief description of the client’s trauma, and some consideration of how the client’s body and mind responded during the event (e.g. dissociation & freeze responses).
• My trauma memories. A space which allows the therapist to introduce important psychoeducation about the nature of trauma memories and their qualities, and also to gather information about aspects of the trauma memory that are repeatedly re-experienced by the client as flashbacks (hotspots).
• Appraisals of the trauma. Client appraisals of their trauma can maintain their heightened sense of threat. The language of ‘appraisals’ is not very client-friendly, and we introduce this aspect of the model as:
  • What I thought then. This might include thoughts that went through the client’s mind at the time of the trauma (e.g. “I’m going to die”, “He’s going to hurt me”) which may or may not have been accurate appraisals of the situation. If memories are re-experienced with a sense of ‘nowness’ these appraisals may also be made in the here-and-now.
  • What I think now. This might include client beliefs about themselves (e.g. “I’m broken”), their role in events (“It was my fault), their future (“I’ll never recover”).
• Triggers. People with PTSD frequently find that their trauma memories can be triggered involuntarily by environmental stimuli.
• What I experience now. This section is designed to capture the client’s current sense of threat, which might include symptoms, emotions, and physiological sensations.
• How I cope. This space is designed to capture coping responses, especially those which might inadvertently serve to maintain the client’s current sense of threat. Coping strategies might be cognitive (e.g. thought suppression) or behavioral (e.g. avoidance).

“One of the first steps in cognitive therapy for PTSD is to come to an understanding of what happened to you, how it affected you, and what is getting in the way of your recovery. I wonder if we could explore some of your history, thoughts, feelings, and reactions to see what kind of pattern they follow?”

1. My trauma. The therapist’s role at this point of the formulation is to help the client to briefly label what happened to them. It is important not to probe for too much detail about the trauma at this point, as it may lead to distress, dissociation, or getting sidetracked – the client can be reminded that there will be an opportunity to talk in detail about the trauma during later memory processing. It is helpful at this point to find out whether the client dissociated during the trauma, or if their body or mind reacted involuntarily in ways that concerned them. The therapist should ideally use the client’s own language to describe what happened to them.

• Can you tell me what happened in a few words, or give me the headlines of what happened?
• What words would you use to describe what happened?
• What did your mind and body do during the trauma? (e.g. freezing, mind going elsewhere).

2. My trauma memories. The purpose at this point is not to ‘process’ the trauma memories, but to begin to gather information about which parts of the trauma memory bother the client most. Research indicates that people with PTSD experience flashbacks (involuntary memories) to a limited number of moments in the memory. An important point for psychoeducation is that memories in PTSD have particular properties (re-experienced in the here and now, vividness, sensory qualities).

• Do your trauma memories ever pop into your mind when you don’t want them to?
• Which parts of the trauma does your mind replay as unwanted memories, flashbacks, or nightmares?
• What physical feelings do you experience with these memories?
• Are your memories visual, or do you ever experience sound, smell, taste, or touch?
• What do you think of yourself for having memories like these? (this question targets the client’s appraisals of trauma memories)

3. Appraisals. At this point of a trauma formulation, the therapist should try to understand the sense that a client has made of what happened to them, both at the time of the trauma, and afterwards. Therapists often make a distinction between peri-traumatic appraisals (thoughts that the client had at the time of the trauma, during the event) and post-traumatic appraisals (sense that the client has subsequently made of the trauma and the effects that is has had). Ehlers & Clark (2000) give a fuller description, but in brief, appraisals can:

• Concern the trauma and immediate events (e.g. “I’m going to die”).
• Concern subsequent consequences (e.g. “I’m going mad”, “Other people think I’m disgusting”).
• Be externally directed (e.g. “The world is unsafe”).
• Be internally directed (e.g. “I am to blame, I am disgusting”).

Questions to elicit appraisals can include:

• What was going through your mind when <trauma> happened?
• What did you think was going to happen at that point?
• What do you think now about: yourself, your symptoms, your actions, or what other people think of you?

4. Triggers. Memories for trauma are often experienced involuntarily, sometimes in the form of flashbacks. Clients are often extremely sensitive to environmental triggers. Therapists will find it helpful to know more about triggers because they can either be approached as stimuli for stimulus discrimination, or targets during memory processing.

• What kinds of things trigger unwanted memories for you? (consider sights, sounds, smells, tastes, touch, people, places).
• What reminders of your trauma do you avoid?

5. What I experience now. The purpose of this section is to help clients understand that the sense of current threat that they experience is a natural consequence of their trauma memories (notably here-and-now re-experiencing), and the way that they appraise their trauma.

• What are the problems that have brought you to therapy?
• When you get triggered, what symptoms, emotions, or body sensations do you experience?

6. How I cope. The purpose of this section is to explore how the client copes with their symptoms and how they are feeling. Coping strategies can be framed as “best efforts to cope” or “understandable responses to feeling that way”. Exploring the client’s coping strategies in PTSD is especially important: Ehlers & Clark propose that some strategies can directly produce PTSD symptoms, and prevent changes in unhelpful appraisals of the trauma, or in the trauma memory itself.

• How do you cope with unwanted memories of what happened? (e.g. keep busy, use substances, push them away)
• How do you cope with thinking <post-traumatic appraisal> about yourself?
• How do you cope with thinking that other people believe that about you?
• What do you avoid? (e.g. people, places, thoughts, memories)
• What do you do to cope?
• When you feel disgusting / ashamed / guilty what do you do?
• How do your coping strategies make you feel? (Explore short term and long term effects)

7. Explore the consequences of coping strategies and implications for treatment. At this stage of an individual formulation, it is helpful for clients to understand the potential consequences of their coping strategies, as these will have a bearing upon later treatment approaches.

• American Psychological Association. (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. Retrieved from http://www. apa.org/ptsd-guideline/ptsd.pdf
• Brewin, C. R. (2014). Episodic memory, perceptual memory, and their interaction: foundations for a theory of posttraumatic stress disorder. Psychological Bulletin, 140(1), 69.
• Brewin, C. R. (2015). Re-experiencing traumatic events in PTSD: New avenues in research on intrusive memories and flashbacks. European journal of psychotraumatology, 6(1), 27180.
• Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour research and therapy, 38(4), 319-345.
• Ehlers, A., Clark, D. M., Dunmore, E., Jaycox, L., Meadows, E., & Foa, E. B. (1998). Predicting response to exposure treatment in PTSD: The role of mental defeat and alienation. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 11(3), 457-471.
• Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM‐IV and DSM‐5 criteria. Journal of traumatic stress, 26(5), 537-547.
• International Society of Traumatic Stress Studies. (2019). Posttraumatic stress disorder prevention and treatment guidelines. Retrieved from http://www.istss.org/getattach ment/Treating-Trauma/New-ISTSS-Prevention-and-Treatment-Guidelines/ISTSS_PreventionTreatmentGuidelines_ FNL.pdf.aspx
• Murray, H., Merritt, C., & Grey, N. (2015). Returning to the scene of the trauma in PTSD treatment–why, how and when? The Cognitive Behaviour Therapist, 8, E28. doi:10.1017/S1754470X15000677
• National Institute of Health and Clinical Excellence (2018). Posttraumatic stress disorder. Retrieved from www.nice. org.uk/guidance/ng116
• Schauer, M., & Elbert, T. (2010). Dissociation Following Traumatic Stress. Zeitschrift für Psychologie/Journal of Psychology, 218(2)
• Wild, J., Warnock-Parkes, E., Murray, H., Kerr, A., Thew, G., Grey, N., ... & Ehlers, A. (2020). Treating posttraumatic stress disorder remotely with cognitive therapy for PTSD. European journal of psychotraumatology, 11(1), 1785818.