Individual differences at the schematic model level

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It is important to elaborate on the types of models of self, world, and others which we propose that the individual holds at the schematic model level of meaning within SPAARS, and how they relate to the individual's prior emotional and developmental history, in order to try to understand the enormous range of individual differences in the way people respond to traumatic events. Dalgleish (2004) has proposed that there are five main types of "pre-trauma personalities" that interact with the nature of the trauma to determine trauma outcome. These five types are balanced, inflexible positive (either valid or illusory), or negative (either world negative with self positive, or world and self negative).

An individual's models of the self, world, and others seem to vary considerably along the dimensions highlighted by authors such as Janoff-Bulman; for example, how safe the world is, how meaningful events in the world are, how vulnerable the individual is, and how positive the view of the self is, and so on. So, some individuals might hold schematic models such as {world - reasonably safe} or {self - generally invulnerable} whereas others might hold models such as {self - completely invulnerable}. In addition to these variations in the models of self, world, and others, we propose that individuals will have developed very different ways of dealing with information that is incompatible with these models thoughout their emotional histories. Some people may have become highly practised at repressing or denying such incompatible information in the past such that it has rarely actually been integrated with the models of the self, world, and others but instead has been fenced off in memory—swept under the emotional carpet (the "inflexible illusory positive" type; see Chapter 10 for a discussion of the repressive coping style). Other individuals will have learnt to deal with information incompatible with their models of the world, self, and others and to process it emotionally (Rachman, 1980, 2001) such that there is a rapprochement between the models and the information (the "balanced type").

Most individuals, we submit, will possess balanced models of the world, self, and others at the schematic model level in which the world is a reasonably safe place, the individual is reasonably safe, and there is a high concordance between the individual's actions in the world and their consequences. In most cases, such models are not overvalued in the sense that, for example, the individual holds an assumption of complete invulnerability. Furthermore, such models are not rigid and inflexible because they are usually the product of a learning history in which the individual has had to process information that is at odds with extant models, and has had to integrate that information in adapting those same models; for example, when goals have not been fulfilled. Consequently, such individuals' models of the self, world, and others—the structures that provide the sense of meaning and reality—have a certain flexibility and potential to adapt to incorporate disparate information. We propose that individuals such as this, namely the majority, will most usually experience an initial period of post-traumatic reactions (although some will be able to integrate the trauma-related information almost immediately) but would normally be able to integrate the traumatic information into their models of the self, world, and others within weeks or months, either within therapy or within their social support networks (and we discuss these processes below). Such individuals would be unlikely to develop chronic PTSD reactions.

Other people will possess what we shall call overvalued models and assumptions about the self, world, and others at the schematic model level. These models can be expressed as propositional beliefs such as that the world is completely safe, or nothing really bad will ever happen to me, and so on. An individual might hold such models of the world for two very different reasons: they may have led a very predictable, controllable, safe life in which things have rarely gone wrong and goals have invariably been fulfilled; that is, the schematic models of self, world, and others might be a reasonable reflection of the life that they have experienced (the "valid inflexible positive" type). Alternatively, they may have evolved a way of dealing with emotional events which has involved the repression and denial of any information that is incompatible with the overvalued models they hold, in order to maintain those models (see Singer, 1990, and Chapter 10). We propose that a characteristic of the models of the self, world, and others of such individuals, whether the models are maintained through repression and denial or are a function of the individual's relatively unscathed past, is that they are likely to be inflexible. In neither case will such individuals have a history of adapting their schematic models in order to accommodate incongruent information.

We suggest that both of these types of supposedly invulnerable individuals are highly vulnerable to extreme emotional distress following a traumatic event but in different ways. The individuals whose pre-trauma life has been safe, controllable, and predictable will have no way of beginning to integrate the trauma-related information into their relatively inflexible models of the self, world, and others; furthermore, they will have no way of defending against its impact. Consequently, they are likely to be most at risk of suffering severe and chronic PTSD. This situation is unlike individuals who over a period of months are able to adapt their schematic models to assimilate the trauma-related information eventually through "emotional processing" (Rachman, 1980, 2001) in therapy or within their social support network. Those with inflexible models will be unable to resolve this tension and are likely to abandon their models of self, world, and others. It is really only these individuals who experience Janoff-Bulman's "shattered assumptions". Most other trauma survivors seem to cling desperately to the models of self, world, and others in order to retain some sense of meaning and some grasp of reality in the face of what has happened. Finally, we submit that chronic post-traumatic stress is characterised by increasingly associatively driven emotion generation.

In contrast, those individuals who have employed a repressive coping style in order to maintain their overvalued models (the "illusory inflexible positive" type) are likely to be able to continue to employ these coping processes fairly effectively in dealing with the new trauma-related information. In these people, then, there will be few outward signs of post-traumatic reactions in most cases (although in the extreme cases they may suffer severe dissociative reactions and psychogenic amnesia). Most usually, we suggest, they will be able to lock the trauma-related information away in memory and throw away the key. Such individuals are likely to be vulnerable to late-onset PTSD when either later life changes shift the way that their schematic models of self, world, and others are organised, or when situations similar to the original trauma occur. For example, in Kuwait a number of individuals developed late-onset PTSD when the Iraqi troops amassed once again at the border between the two countries some 2 years after the original invasion (Dalgleish & Power, 1995). Life events such as these may be sufficient to overwhelm the system that is already trying to repress the information related to the previous trauma; late-onset PTSD is then likely to occur.

There are of course individuals who have premorbidly damaged models of the self, world, and others; that is, they already have schematic model representations that the world is not safe, that they are vulnerable, and so on (the "negative world, negative self" type). Such individuals may even have a premorbid psychiatric history. These people, we would speculate, are either (1) likely to have their models confirmed by the new traumatic information, in which case we propose that they are likely to experience increases in their associated feelings of anxiety and depression concerning the trauma rather than severe PTSD symptomatology; or (2) their premorbid models of the world are more threat-related with respect to minor negative events, but extremely positive with respect to the kind of low-probability, high-cost events that usually constitute traumas. However, there is a further group of individuals who typically work in the emergency services and who are constantly reminded therefore of how negative the world is, but how positive they are in themselves in the face of such negativity (the "negative world, positive self" type)—Geoff, the case study at the beginning of this PTSD section, would fit into this category. Post-trauma stress reactions are increasingly observed in such individuals, although sometimes these reactions are not primarily fear-based, but are disgust- or anger-based reactions, a point that we will expand on next.

The final point that we wish to make in this section is about the core emotion that is involved in a post-trauma stress reaction. Although the classification systems such as DSM-IV (APA, 1994) have classified PTSD as an anxiety-based disorder, and we have followed suit by the inclusion of PTSD in this chapter on anxiety, it is clear now that many PTSD reactions are not primarily anxiety-based (Dalgleish & Power, 2004b). To give examples, the emergency worker who finds a partly decomposed body in a bedroom may have a primarily disgust-based reaction; similarly an adolescent who was eating a slice of cake but then started chewing a blackened fingernail developed disgust-based PTSD (the details of these clinical cases are presented in Dalgleish & Power, 2004b). Anger-based PTSD can often be found in victims of accidents, though sometimes coupled with fear reactions. And sadness-based PTSD can occur in cases of traumatic loss such as sudden and unexpected bereavements following the loss of a loved partner or child; thus, studies of pathological bereavement show a considerable overlap with PTSD symptomatology (e.g. Jacobs, 1999; Schuchter, Zisook, Kirkorowicz, & Risch, 1986). As an informal check on this proposal, following discussion about the relevant basic emotions, we asked our colleagues in the Rivers PTSD Centre in Edinburgh to classify current clinical cases as primarily anxiety-, disgust-, anger-, or sadness-based trauma reactions. The results showed that out of a total of 77 current cases, 44 (57%) were classified with anxiety as the primary emotion, but the remaining 43% were classified with sadness (13%), anger (19%), or disgust (8%) as the primary emotion and a further two cases (3%) classified with anxiety and sadness as equal primary emotions. The main point to draw from this informal study, apart from the fact that we need to replicate it more systematically, is that emotions other than anxiety-based ones may be the primary emotions involved in 40-50% of cases who go on to develop PTSD; that is, this proposal does not simply refer to one or two exceptional cases, but to nearly half of clinical cases, and therefore may have substantial implications for both theoretical models of PTSD and for its treatment (see Dalgleish & Power, 2004b, for an extended discussion).

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