Cognitive Vulnerabilities to the Development of PTSD: A Review of Four Vulnerabilities and the Proposal of an Integrative Vulnerability Model

The featured paper is ‘Cognitive Vulnerabilities to the Development of PTSD: A Review of Four Vulnerabilities and the Proposal of an Integrative Vulnerability Model’ by Lisa Elwood and colleagues.

This is a review paper with a brief aims and method section included in the introduction.

The authors give some background on Post Traumatic Stress Disorder (PTSD) telling the reader how the term originated in the need to recognise the presentation of a number of Vietnam Veterans on returning to the USA in the original incorporation into DSM-II and the subsequent subtle reorganisation of the term in DSM-IV. The natural course of research has been to focus on who develops PTSD in order to better characterise the condition. A number of factors were identified from meta-analyses which influenced the development of PTSD including peri-traumatic dissociation, support networks and severity of the trauma. However the caveat was that these risk factors differed across different trauma situations and populations reinforcing the complexity of the phenomenon.

The authors then discuss how the diathesis-stress model has been developed for psychological phenomenon. The term diathesis has greek origins where it refers to a predisposition. The diathesis-stress model states that a person may have a predisposition towards developing a certain condition but must first experience a certain stressor. The authors describe psychological diatheses as

‘relatively stable individual differences..that increase one’s vulnerability to stress and to the development of psychological disorders’

The authors then examine types of relationships between ‘factors’ and disorders – some for instance are considered ‘necessary and sufficient’ while others have a less prominent role. The authors argue that vulnerability factors are causally related to a condition and may serve as a maintaining factor.  They go onto remark that

‘A full diathesis-stress model of PTSD must account for pre-, peri- and post-trauma factors’

The authors provide an integrated model containing the following components:-

  • Cognitive theories of PTSD
  • Negative Attributional Style
  • Rumination
  • Anxiety Sensitivity
  • Looming Cognitive Style
  • Additional Vulnerabilities

In cognitive theories of PTSD, the authors discuss some of the history of the field. The authors identify a number of different hypotheses in this area and cite a suggestion that having more positive assumptions prior to trauma would be more likely to predispose to development of PTSD. They look at emotional processing theory in which habituation is thought to play a role and they examine briefly mechanisms of interference with habituation.They also examine a number of theories before looking at measurement of cognitive beliefs using the Posttraumatic Cognitions Inventory (PTCI). The authors focus on the relationship between depression, anxiety and PTSD suggesting that diatheses for the former conditions could be examined in PTSD.

In addressing negative attributional style, the authors describe this as a tendency to attribute causality for negative events internally, as well as to believe that such events will ‘always happen’ in ‘all areas of their lives’ (effectively using dichotomous and inductive reasoning about negative events). The authors examine the Attributional Style Questionnaire (ASQ) looking closely at reliability and validity as well as a number of alternative measures and other supportive evidence for the usefulness of these constructs. The authors then review the literature on negative attributional style and PTSD with evidence being found both for and against a relationship.

The authors describe rumination as a tendency to focus repetitively on a number of factors including negative emotions and symptoms of distress and cite studies showing a relationship between rumination and depression. The Ruminative Response Scale of the Response Style Questionnaire is examined in terms of reliability and validity.  The authors identify a diverse range of measures being used in PTSD research to look at rumination. The authors identify a theoretical model in which rumination after a traumatic event leads to avoidance of trauma processing. However in the literature they find studies both in support and against this model.

The authors explain anxiety sensitivity as a fear of the symptoms which are associated with harmful consequences and describe this as a trait which likely consists of several factors and is associated with a number of anxiety disorders. They focus on the Anxiety Sensitivity Index looking at reliability and factors in the construct. They look at supporting evidence for construct validity in research looking at agoraphobia in particular. In PTSD research they identify research supporting the relationship between anxiety sensitivity and development of PTSD symptomatology as well as coping mechanisms in PTSD.

In examining the Looming Cognitive Style the authors explain this as a person’s interpretation of threats (both in the future and present) which invokes mental representation with biased threat appraisals. The authors examine the Looming Maladaptive Style Questionnaire in terms of validity. They note that there is sparse research on the relationship between the LCS and PTSD although there is some supporting evidence for increasing LCS scores being related to increasing PTSD symptom endorsement. A number of other vulnerability factors are covered briefly including neuroticism and emotional dysregulation.

Given the nature of the questions being asked, perhaps there is a case for a meta-analysis in this area and indeed the authors discuss this in the conclusion.This is a useful paper, with the authors having covered a large amount of literature on the subject and organised it around a number of constructs which might contribute to the development of PTSD.

Steps to Treatment = 4 (Development of a model, informing treatment approach, successful trial, agreement for and incorporation into policy)


Lisa Elwood, Kathyrn Hahn, Bunmi Olatunji and Nathan Williams. Cognitive Vulnerabilities to the Development of PTSD: A Review of Four Vulnerabilities and the Proposal of an Integrative Vulnerability Model. Clinical Psychology Review. 29. 2009. 87-100.


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The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.


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