Behavioral-Cognitive Inhibition Theory: Conceptualization of Posttraumatic Stress Disorder and Other Psychopathology Disorders

doi:10.4236/psych.2010.15044

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Psychology

2010. Vol.1, No.5, 349-366

Behavioral-Cognitive Inhibition Theory:

Conceptualization of Posttraumatic Stress Disorder

and Other Psychopathology Disorders

Nenad Paunović

Center for Andrology and Sexual Medicine, Karolinska University Hospital, Stockholm, Sweden.

Email: kontakt@kbterapi.se

Received September 9th, 2010; revised October 5th, 2010; accepted October 11th, 2010.

A comprehensive and behaviorally formulated theory for psychopathology disorders termed as behaviora l-cog-

nitive inhibition theory is presented. It constitutes an integration and re-formulation of several influential psy-

chological theories of psychopathology and empirical findings in imagery research. According to the b eh avior-

al-cognitive inhibition theory the development of PTSD and other psychopathology disorders are due to the de-

velopment of dysfunctional respondent-functional-appraisal memories. The maintenance of psychopathology

disorders is due to a continuous retrieval of dysfunctional respondent-functional-appraisal memories, to inhibit -

tion of incompatible respondent-functional-appraisal memories, and to current dysfunctional appraisals and be-

haviors. Dysfunctional and incompatible respondent-functional-appraisal memories consist of respondent, dis-

criminative, behavioral response, appraisal and consequence memory elements. It is proposed that the recovery

from PTSD and other psychopathology disorders is accomplished when (a) strong enough matching incompati-

ble respondent-functional-appraisal memories are retrieved in the same circumstances as dysfunctional respon-

dent-functional-appraisal memories, (b) dysfunctional respondent-functional-appraisal memories become inhi-

bited by incompatible respondent-functional-appraisal memories, and (c) new incompatible or functional con-

tingencies are encoded, stored and become effective incompatible respondent-functional-appraisal memories.

Concrete examples of respondent-func t ional-appraisal memory elements in emotional and personality disorders

are presented. In addition, incompatible respondent-funct ional-appraisal memory elements are presented. Fur-

thermore, central hypotheses of the behavioral-cognitive inhibition theory are formulated and important issues

are discussed.

Keywords: Behavi oral-Cognitive Inhibition Theory, Comorbidity, Respondent, Functional, Appraisal, Memories,

Posttraumatic Stress Disorder, Emotional and Personality Di sor ders

Introduction

There are several influential theories for PTSD that have in-

fluenced the development of effective treatments for PTSD

(e.g., Brewin, Dalgleish, & Joseph, 1996; Ehlers & Clark, 2000;

Foa et al., 1986; Foa et al., 1989, Keane et al., 1995). However,

no theory has provided a comprehensive behaviorally formu-

lated conceptualization of PTSD and comorbid emotional and

personality disorders. It is proposed that the behavioral-cogni-

tive inhibition theory may be able to do so. The idea of multiple

respondent-functional-appraisal memories conceptualized as a

network that is used to explain comorbidity comes from multi-

ple representational theories (Brewin et al., 1996; Power &

Dalgleish, 1997). Multiple psychopathology-related respondent-

functional-appraisal memories are conceptualized on the basis

of identical terminology and theoretical mechanisms which

solves (a) the interaction between multiple components problem

(Dalgleish, 2004), and (b) the overdetermination problem that

occurs when identical symptoms are explained by two different

theories within one overarching model (e.g., when re-experi-

encing symptoms are due to activated fear structures and sche-

ma conflicts, Foa & Rothbaum, 1998).

In addition to comorbidity, it is proposed that the behavioral-

cognitive inhibition theory improves upon influential PTSD

theories and other psychopathology-specific CBT theories on

other important issues. The behavioral-cognitive inhibition

theory improves upon the emotional processing theory in sev-

eral ways. First, the components are formulated in behavioral

terms. This is in contrast to the hypothetical schema concepts

(Foa & Rothbaum, 1998). Second, the conceptualization of

“incorporation of corrective/new information” as a therapeutic

goal is not in itself an optimal formulation. It is important to

broaden such a conceptualization by also including the incor-

poration of the following memory elements: respondent, dis-

criminative, functional and consequence memory elements.

Third, the numbing symptoms are more comprehensively ex-

plained (e.g., Follette & Naugle, 2006; Litz, Orsillo, Kaloupek,

& Weathers, 2000). According to Taylor (2006) numbing

symptoms are suboptimally explained by influential PTSD

theories. Fourth, the behavioral-cognitive inhibition theory

separates between primary and secondary respondent-function-

al-appraisal memories that aids in the selection of treatment

priorities.

The behavioral-cognitive inhibition theory behaviorally for-

mulates vital components of the cognitive theory for PTSD

developed by Ehlers and Clark (2000). Peri-traumatic apprais-

als are conceptualized as trauma-related primary appraisal me-

mories, disjointed fragmentary memories as respondent and/or

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350

discriminative trauma-related memories, and “hotspots” as

primary respondent memories. Peri-traumatic appraisals may

include correct appraisal memories of threat or any other aspect

that occurred during a traumatic event or faulty appraisal mem-

ories encoded and stored during and/or after the event. Trau-

ma-related primary behavioral response memories of being e.g.

passive or assertive during the trauma (behaviorally and/or

cognitively) may influence current behaviors. Consequence

memories of what happened immediately after the trauma may

be correct or incorrect. It is important to correct faulty primary

memories, to learn to discriminate between correct primary

memories and current contingencies and to drop safety and

avoidance behaviors in current contingencies that hinder the

development of functional discriminations and appraisals. Such

a behaviorally formulated conceptualization may be relevant to

other emotional and personality disorders in addition to PTSD.

The behavioral-cognitive inhibition theory provides a com-

prehensive behaviorally formulated conceptualization of PTSD

and/or other psychopathology symptoms as a result of both type

1 and type 2 traumatic events (Terr, 1991). Type 1 traumatic

events include unanticipated single traumatic events. Type 2

traumatic events consist of long-standing or repeated exposure

to traumatic events. The behavioral-cognitive inhibition theory

may be able to explain dissociative symptoms and traumatic

amnesia more often seen in victims of type 2 traumatic events

(Terr, 1991), and more extreme flashbacks. Type 2 traumatic

events may be encoded and stored as extremely dysfunctional

respondent-functional-appraisal memories that include (a) ex-

treme dissociative response and avoidance behavior memories

leading to an automatic shutdown when such a memory is re-

trieved, and (b) extreme respondent memories that result in

severe flashbacks when retrieved. Furthermore, the behav-

ioral-cognitive inhibition theory may provide a plausible con-

ceptualization of PTSD-related psychological disturbances seen

in particularly vulnerable PTSD populations such as individuals

with PTSD and comorbid substance abuse (Najavits, 2001),

adult child sexual and physical abuse survivors (Cloitre, Cohen,

& Koenen, 2006), personality disorders (Young, Klosko, &

Weishaar, 2003), various types of vulnerable PTSD client pop-

ulations (Mueser, Rosenberg, & Rosenberg, 2009), and trauma-

tized children (e.g. Cohen, Deblinger, & Mannarino, 2006;

Smith, Perrin, Yule, & Clark, 2009). Examples of distur-

bances may include, but are not limited to, poor emotion regu-

lation, excessively dysfunctional interpersonal cognitions and

arrested cognitive and social development.

In addition to traumatic events, it ought to be possible to use

typologies in order to describe variations of other types of dis-

tressing life events, for example distressing social experiences.

A hypothetical example is described next. Type 1 distressing

social events may include occasional or few social events that

are quite distressing (e.g. experiencing occasional social harsh-

ness, criticism etc.). Type 2 distressing social events may en-

compass extremely distressing social events that have occurred

repeatedly and/or for a long duration. One type of such event

may be repeated bullying in school that many children may

have experienced. Such experiences have been found in the

majority of sexual offenders at the author’s work place at the

Karolinska university hospital in Stockholm specialized in the

treatment of sexual disorders.

Other types of events that may be categorized according to

typologies in order to illustrate variations are those that are

incompatible to distressing life events. For example, life events

that are pleasurable, nurturing and that boost self-efficacy. A

fi ne-grained analysis of the interaction between the current

situation and personally meaningful encoded and stored res-

pondent-functional-appraisal memories may be important in

order to more fully understand the development and mainte-

nance of psychopathology disorders.

The behavioral-cognitive inhibition theory is influenced by

the learning theory (Baldwin & Baldwin, 2001; Keane, Zimer-

ing, & Cadell, 1985; Martin & Pear, 2007), emotional process-

ing theory (Foa & Kozak, 1986; Foa & Rothbaum, 1998; Foa,

Steketee & Rothbaum, 1989), cognitive theory (Beck, Emery &

Greenberg, 1985; Beck, Rush, Shaw, & Emery, 1979; Clark,

1999; Ehlers & Clark, 2000), schema theory of personality

disorders (Young et al., 2003), imagery research in emotional

disorders (Hackman & Holmes, 2004; Holmes, Arntz, &

Smucker, 2007), multi-representational theories (Brewin et al.,

1996; Power & Dalgleish, 1997), retrieval competition theory

(Brewin, 2006), behavioral-cognitive vulnerability models

(Barlow, 2002), stress appraisal theory (Lazarus & Folkman,

1984), reciprocal inhibition theory (Wolpe, 1995), conceptuali-

zations of numbing symptoms in PTSD (Follette & Naugle,

2006; Litz, 1992), and the prolonged exposure countercondi-

tioning method (Paunovic, 1999; 2002; 2003).

Central hypotheses that can be deduced from the behavioral-

cognitive inhibition theory are the following. First, that re-

spondent-functional-appraisal memories can be functional and

dysfunctional. In PTSD and other psychopathology disorders

such memories are excessively dysfunctional when their re-

trieval leads to/influences: (i) excessively distressing respon-

dent responses, (ii) dysfunctional predictions and appraisals, (iii)

dysfunctional behavioral responses, (iv) dysfunctional conse-

quences such as the continuation of psychopathology symptoms

and negative consequences at work, during leisure time and

impoverished relationships, (v) a lack of/the inhibition of func-

tional respondent-functional-appraisal memory elements.

Second, dysfunctional respondent-functional-appraisal memo-

ries can be optimally inhibited by incompatible respondent-

functional-appraisal memories under the following conditions

(a) when strong or compelling enough incompatible respon-

dent-functional-appraisal memories are retrieved, (b) when

incompatible current contingencies are encoded and stored, (c)

when one or both of the first two conditions occur in the same

circumstances as when psychopathology-related respondent-

functional-appraisal memories are retrieved, (d) when incom-

patible respondent-functional-appraisal memories match central

characteristics of dysfunctional respondent-functional-appraisal

memories, and (e) when all dysfunctional respondent-function-

al-appraisal memories have been retrieved and inhibited. Third,

current behaviors and appraisals are influenced by original

encoding and storing, subsequent instances of retrieval, and

current contingencies. When dysfunctional respondent-func-

tional-appraisal memories are retrieved they may elicit exces-

sive negative emotions, aversive physiological reactions, faulty

appraisals and predictions and dysfunctional behavioral im-

pulses. This may motivate an initiation of dysfunctional res-

ponses such as avoidance, safety behaviors and/or escape that

shuts down the dysfunctional respondent-functional-appraisal

memories. Fourth, it is proposed that dysfunctional primary

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351

memories should be the prioritized treatment target when dys-

functional respondent-functional-appraisal memories are the

result of type 1 traumas that has led to the development of cir-

cumscribed PTSD psychopathology or any other type of cir-

cumscribed psychopathology. When dysfunctional respon-

dent-functional-appraisal memories are associated with a broad

range of psychopathology symptoms as a result of type 2 trau-

mas primary and secondary respondent-functional-appraisal

memories as well as training in necessary skills may be essen-

tial. Fifth, there ought to be an interaction effect between de-

grees of distressing/functional life events a person has encoded

and stored permanently in memory vs. the degree of successful

behavioral coping and functional appraisals that may be

achieved in response to such events and memories.

Behavioral-Cognitive Inhibition Theory

The behavioral-cognitive inhibition theory consists of two

main parts. First, it proposes that there exists dysfunctional vs.

functional respondent-functional-appraisal memories that in-

fluence each other bi-directionally, and that current symptoms,

appraisals and behaviors vs. respondent-functional-appraisal

memories influence each other bi-directionally (see Figure 1).

Second, current contingencies consist of retrieval triggers of

respondent-functional-appraisal memories, current behaviors,

appraisals and consequences. Such contingencies influence

respondent-functional-appraisal memories both directly and

indirectly through the encoding and storing of current contin-

gencies that may develop into respondent-functional-appraisal

memory elements.

Note. Upper figures: RM = respondent memories, DM = discriminative memories,

BRM = behavioral response memories, AM = appraisal memories, CM = conse-

quence memories. Lower figure: UCS = unconditioned stimulus; UCR = uncondi-

tioned response; CS = conditioned stimulus; CR = conditioned response; SD =

discriminative ess-dee stimulus; SΔ = discriminative ess-delta stimulus; BR =

behavioral response, A = appraisal, S+ = reinforcement; S- = punishment.

Figure 1.

Illustration of (a) the interaction between dysfunctional vs. incompati-

ble respondent-functional-appraisal memories (R FAMs; see figures

above), and (b) the interaction between RFAMs vs. current respon-

dent-functional-appraisal contingencies.

Respondent-F unctional-Appraisal Memories

It is proposed that respondent-functional-appraisal memories

can exert an influence on current symptoms, behaviors and

appraisals. Also, respondent-functional-appraisal memories can

be incompatible or functional vs. dysfunctional. Each respon-

dent-functional-appraisal memory consists of the following

elements: respondent, discriminative, appraisal, behavior and

consequence memory elements. Respondent-functional-ap-

praisal memory elements can be primary or secondary. The

behavioral-cognitive inhibition theory on a single respondent-

functional-appraisal memory level is presented in Figure 1.

Respondent Memories

Primary respondent memories consist of primary respondent

stimuli and primary respondent response memories. Dysfunc-

tional primary respondent memories in PTSD and other psy-

chopathology disorders are illustrated in table 1 and 2. Dys-

functional primary respondent memories are acquired as fol-

lows. During or in proximity to excessively negative life events

(unconditioned stimulus = UCS) individuals react with exces-

sive negative emotions, physiological responses and/or bodily

pain reactions (unconditioned responses = UCR). Both UCS

and UCR are encoded by the individual’s sensory apparatus and

stored as primary respondent stimuli memories and primary

respondent response memories respectively. In people who

inherit a biological predisposition to react very strongly emo-

tionally to negative environmental changes (Barlow, 2002)

primary respondent stimuli memories are more likely to be-

come associated with excessively distressing primary respon-

dent response memories.

In PTSD primary respondent stimuli memories consist of

central memories of the traumatic event (e.g., violent acts

committed by a perpetrator or a violent motor vehicle crash).

Primary respondent response memories include excessive un-

conditioned emotional responses of fear, horror, helplessness,

physiological responses and bodily pain. The retrieval of dys-

functional primary respondent memories of a traumatic event is

manifested as (a) vivid trauma-related intrusions of the gist of

the trauma (i.e., visual images, sounds, actions, smells, etc.),

and (b) excessively strong negative emotions, physiological

responses and bodily pain that are identical or very similar to

those experienced during the gist of the trauma.

Dysfunctional secondary respondent memories consist of (a)

encoded and stored peripheral respondent stimuli and responses

that occurred during and/or in close proximity to primary nega-

tive events, and (b) encoded and stored post-event stimuli and

responses that have become associated with dysfunctional pri-

mary respondent memories during the retrieval of the latter.

Secondary respondent memories may through their associations

with primary respondent memories start to function as retrieval

triggers of the latter. Secondary respondent memories associ-

ated with post-event respondent stimuli and responses are ac-

quired when neutral stimuli become encoded and stored during

the retrieval of primary respondent memories. Previously neu-

tral post-event stimuli acquire a function as retrieval triggers of

primary respondent memories. The development of an i ncreas-

ing number of various types of secondary respondent memories

makes it increasingly difficult to avoid retrieval triggers and the

retrieval of primary respondent memories.

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Incompatible primary respondent memories are acquired by

the same mechanisms as dysfunctional primary respondent

memories (e.g., Paunovic, 1999, 2002, 2003). When life events

(UCS) elicit pleasurable or functional UCR (e.g. pleasurable

emotions of happiness, joy, competence etc.), these UCS and

UCR become encoded and stored as incompatible primary re-

spondent stimuli and primary respondent response memories.

Incompatible secondary respondent memories are acquired

during (a) the encoding and storing of peripheral stimuli and

responses during and/or in close proximity to primary i ncom-

patible/pleasurable events, and (b) the encoding and storing of

post-event neutral stimuli that become associated with retrieved

incompatible primary respondent memories. Such secondary

respondent memories acquire the function of retrieval triggers

of incompatible primary respondent memories. An increasing

number of neutral stimuli may acquire such retrieval properties.

When current contingencies and retrieved dysfunctional pri-

mary respondent memories don’t match each other they should

be discriminated from each other. On the other hand, in poten-

tially or realistically harmful situations dysfunctional primary

respondent memories may have a protective and/or preparatory

function that signal what may going to happen.

Stimuli and responses may be encoded through three learning

pathways: direct experience, observational learning and/or in-

formation/instruction (e.g., Rachman, 1976, 1977). Storing

(processing) may occur from (a) other people’s viewpoint

(Hackmann, Surawy, & Clark, 1998), (b) an observation per-

spective (e.g., peritraumatic dissociation), or (c) an individual’s

own viewpoint (e.g. a traumatic event). The encoding may occur

through various sensory channels and become stored accord-

ingly. The most common memory quality in PTSD is visual

memories of the trauma (Ehlers, Hackman, Steil, Clohessy,

Wenninger, & Winter, 2002). Incompatible stimuli and respon-

ses may also be encoded through three different pathways and

various sensory channels, and stored from different viewpoints.

Discriminative Memories

Discriminative memories have predictive functions. When

discriminative memories are retrieved in current contingencies

predictions are made about the consequences of various courses

of actions and/or about what will happen in a given situation.

Dysfunctional primary discriminative memories consist of

encoded and stored peripheral stimuli and responses that oc-

curred in close proximity to negative life events that were in-

volved in the development of psychopathology symptoms. The

retrieval of dysfunctional primary discriminative memories in

innocuous current contingencies may lead to faulty predictions

since they don’t match the current situation. The retrieval of

primary discriminative memories is manifested by intrusions of

peripheral trauma-related memories (pre- and post-event). The

retrieval of PTSD-related primary discriminative memories

serves a function of faulty warning signals of serious threat

(Ehlers et al., 2002). It is proposed that the same mechanism

exists in other psychopathology disorders with psychopatholo-

gy-specific erroneous predictive functions (see Table 1 and 2).

Dysfunctional secondary discriminative memories consist of

encoded and stored neutral stimuli that have become associated

with retrieved primary discriminative memories. Retrieved

secondary discriminative memories may function as retrieval

triggers of primary discriminative memories and may acquire

similar predictive functions as the latter. The development of an

excessive number of various types of dysfunctional secondary

discriminative memories may lead to excessive amounts of

faulty predictions in various types of innocuous situations.

Functional primary and secondary discriminative memories

include correct predictions in line with what will most probably

happen in current contingencies, including if various courses of

actions are taken. Functional primary and secondary discrimi-

native memories are developed as a result of increasingly cor-

rect discrimination learning experiences of the predictive func-

tions that various types of stimuli and responses have. Func-

tional discrimination learning is dependent upon taking courses

of actions in innocuous situations that challenges dysfunctional

and incorrect predictions. Corrective experiences that discon-

firm faulty predictions when dysfunctional primary and second-

dary discriminative memories are retrieved will be encoded and

stored as functional discriminative memories. If such functional

discriminative memories become compelling or strong enough

they acquire the capacity to inhibit dysfunctional discriminative

memories. When functional primary and secondary discrimina-

tive memories are retrieved they will instigate correct predict-

tions regarding what will happen in the retrieval situation and

what consequences a given behavior will have. This increases

the probability that the individual will engage in functional

coping behaviors. The disconfirmation of predicted negative

consequences during the retrieval of dysfunctional discrimina-

tive memories is not possible to acquire if dysfunctional be-

havioral responses are enacted. Such behavioral responses hin-

der corrective experiences from being acquired that may change

the predictive stimulus functions of retrieval triggers. Correct

predictions may in potentially dangerous or in other ways

harmful situations signal that escape, avoidance or appropriate

defensive behaviors are highly functional.

Behavioral Response Memories

There are three fundamental ways to cope with psychologi-

cally or physically potentially harmful situations or negative

events: (a) avoidance, escape and safety behaviors, (b) attack or

resistance, or (c) freezing which is an innate non-volitional

response that is elicited when escape or aggression is not possi-

ble during an attack (e.g., Barlow, 2002, pp. 219-220, 283).

Alternatively, the freezing response may be an unconditioned

respondent response. Such behavioral responses are encoded

and stored as primary behavioral response memories that may

become dysfunctional if their retrieval instigates inappropriate

responses in current contingencies. Dysfunctional primary be-

havioral response memories may function as predispositions to

respond dysfunctionally when current contingencies retrieve

such memories. The retrieval of dysfunctional primary behav-

ioral response memories may increase the risk of responding

similarly in current innocuous situations. This may lead to

short-term relief due to a temporary shut-down of retrieved

dysfunctional respondent-functional-appraisal memories.

Secondary dysfunctional behavioral response memories con-

sist of encoded and stored dysfunctional coping behaviors that

have been enacted during the retrieval of dysfunctional respon-

dent-functional -appraisal memories in innocuous situations.

Such dysfunctional behavioral coping may constitute psycho-

pathology symptoms per see (e.g., avoidance in PTSD [APA,

1994]). The retrieval of dysfunctional secondary behavioral

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Note. 1 Interpersonal and environmental consequence memories are depicted in this table. In addition, negative reinforcement after avoidance behaviors and self-reinforcing/pu nishing behaviors also

become encoded and stored consequence memories.

Table 1.

Dysfunctional primary respondent and/or consequence memories, appraisals and behavioral responses in psychopathology disorders.

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Table 2.

Examples of dysfunctional primary respondent and consequence memories, appraisals and behavioral responses in personality disorders (re-formulated from Young et al., 2003).

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response memories increases the probability of engagement in

dysfunctional behavioral coping when intrusions and other

symptoms occur in innocuous situations. Behaviors such as

avoidance, escape or attack are associated with faulty predictive

functions. This includes the faulty prediction that negative con-

sequences will be neutralized or minimized if such behaviors

are pursued.

Some emotional behaviors have a communicative function

(Barlow, 2002) that can be concealed. Individuals with PTSD

deliberately conceal or withhold emotional expression (Roemer,

Litz, Orsillo, & Wagner, 2001). This withholds the necessary

emotional communication that is needed in order to receive

social support from others. The absence of social support may

be encoded and stored without an awareness that this is due to

the emotional concealment behavior. Alienation and emotional

distancing from others may in part be related to the retrieval of

such behavioral response (emotional concealment) and conse-

quence memories (lack of social support). Functional behaviors

such as telling about the trauma to others may lead to social

support. However, distress in significant others, beliefs that it is

harmful to talk about distressing events, and dysfunctional re-

sponses such as avoidance and escape by significant others may

lead to an absence of or inadequate social support.

Incompatible behavioral response memories may be acquired

during distressing, neutral and/or positive situations. Memories

of successful coping behaviors in distressing situations or par-

ticipation in appreciated activities promote successful coping

and participatory enjoyment in future similar situations. If

communicating negative events and emotions to others leads to

social support both the behavior, emotions, stimuli in the situa-

tion and related appraisals become encoded and stored as in-

compatible respondent-functional-appraisal memories. Engage-

ment in appreciated activities may include activities related to

valued relationships, activities, goals etc. The retrieval of such

behavioral response memories may lead to an increased prob-

ability that similar behaviors will be enacted in current circum-

stances.

Cognitive behavioral responses have identical functions as

their overt behavioral counterparts. Dysfunctional cognitive

primary behavioral response memories consist of encoded and

stored dysfunctional cognitive behavioral responses. These may

include peritraumatic dissociation, perceptual avoidance, dis-

traction and obsessive cognitive behaviors. Pe r it raumatic dis-

sociation (Ozer & Weiss, 2004) may have a protective function

against overwhelming emotions during a traumatic event. Dur-

ing post-event retrieval of peritraumatic dissociation memories

numbing responses may ensue. Perceptual avoidance is a sur-

vival mechanism that has been found in adult survivors of child

sexual and physical abuse with complex PTSD (Kohlenberg,

Tsai, & Kohlenberg, 2006). Its function seems to be an avoid-

ance of encoding retrieval triggers of the abuse, the abuser and

associated emotions, particularly if physical escape may not be

possible. Otherwise the effects of the trauma would be more

intrusive and preclude any caretaking. Downsides includes a

compromised ability to identify, experience and describe emo-

tions. Distraction consists of a purposeful attentional focus

away from distressing stimuli and responses. Obsessive cogni-

tive behaviors are excessively repetitive cognitive responses

whose function is to decrease distressing events, images or

impulses.

Secondary dysfunctional cognitive responses include distrac-

tion, effortful suppression, obsessions, ruminations, worries,

cognitive safety behaviors, dissociation and trying not to think

about negative memories or events (e.g. Barlow, 2002; Ehlers

& Clark, 2000; Foa & Kozak, 1986; Kubany & Ralston, 2006;

Watkins, 2008). These cognitive responses are encoded and

stored as secondary cognitive behavioral response memories.

When dysfunctional cognitive behavioral response memories

are retrieved they may (a) block the retrieval of other dysfunc-

tional respondent-functional-appraisal memories, and (b) mo-

tivate similar responses to current distressing stimuli and emo-

tional responses.

Incompatible primary cognitive behavioral responses may be

encoded during primary distressing, neutral or positive events/

situations and stored as incompatible primary cognitive behav-

ioral response memories. An individual may cope cognitively

successfully in distressing situations. Cognitive mastery re-

sponses may consist of an ability to nurture/calm oneself, elicit

positive emotions or functional physiological states, approach

situations imaginally while maintaining a sense of control etc.

Mental planning is defined as thinking about or planning in

one’s mind about what one might be able to do to minimize

physical or psychological harm, to make the experience more

tolerable, or to influence the response of an assailant during a

traumatic event (Ehlers, Clark, Dunmore, Jaycox, Meadows, &

Foa, 1998).

Incompatible secondary cognitive behavioral responses are

encoded and stored during the retrieval of primary respondent-

functional-appraisal memories. There are at least three types of

secondary incompatible or functional cognitive behavioral re-

sponses that can be enacted. First, cognitive approach behaviors

during the retrieval of distressing respondent-functional-ap-

praisal memories such as in imaginal exposure to a traumatic

event (Foa & Rothbaum, 1998). Second, effortful retrieval of

incompatible respondent-functional-appraisal memories of e.g.

valued events with significant others, appreciated activities,

competency situations etc (e.g., Paunovic, 1999; 2002; 2003).

Third, imagery rescripting of dysfunctional respondent-func-

tional-appraisal memories by imaginally changing negative

courses of events into mastery and nurturing experiences (e.g.,

Holmes et al., 2007).

A lack of incompatible behavioral response memories may

be due to skills deficits. Important skills include social, motoric

and intellectual skills. Skills deficits may likely lead to failed

coping attempts that become encoded and stored as dysfunc-

tional behavioral response memories. If relevant skills are de-

veloped it increases the probability of successful coping and

adaptive behaviors in appropriate situations. Such successful

coping is encoded and stored as an incompatible behavioral

response memory. The retrieval of such memories constitutes

indications that one has the capability to successfully cope with

the relevant situations.

Appraisal Memories

Dysfunctional primary appraisal memories are acquired as

follows. During primary negative events, innate and automatic

appraisals may be elicited and/or conscious appraisals deliber-

ately enacted. These appraisals are encoded and stored as pri-

mary appraisal memories. In PTSD primary appraisals include,

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356

but are not limited to, serious life threat or threat of harm and/or

helplessness. If distressing emotions are not correctly associ-

ated with the eliciting negative life event within the next few

hours, the individual may be unable to specify an antecedent to

the distressing emotions (Barlow, 2002). In addition, an indi-

vidual may incorrectly appraise the situation in a dysfunctional

way. As a result, dysfunctional primary appraisal memories

may develop that contains faulty appraisals not associated with

the eliciting events and/or incorrect appraisals of the situation.

During the post-event sequel, retrieved primary appraisal

memories may be incorrectly attributed to current contingencies

rather than to the nature of retrieval triggers and dysfunctional

respondent-functional-appraisal memories.

Dysfunctional secondary appraisal memories may develop

during the retrieval of primary respondent-functional-appraisal

memories. Retrieval triggers may be incorrectly appraised dur-

ing intense negative emotions. Such appraisals are encoded and

stored as dysfunctional secondary appraisal memories. In PTSD

negative appraisals in the trauma aftermath predict the mainte-

nance of PTSD (e.g., Ehlers, Mayou, & Bryant, 1998; Engel-

hard, van den Hout, Arntz, & NcNally, 2002). The content of

PTSD-related appraisal memories include catastrophic and

dysfunctional appraisals of trauma intrusions and trauma trig-

gers as extremely dangerous, that PTSD symptoms are indica-

tions of self and the future in negative ways, and that other

people’s behaviors are indications that they are not trustworthy

and understanding (Ehlers & Clark, 2000; Foa & Rothbaum,

1998).

Dysfunctional appraisal memories are logically associated

with other respondent-functional-appraisal memory elements.

In addition, repetitive appraisals associated with e.g. guilt, an-

ger or shame may become habitually conditioned with images

or thoughts of the trauma (i.e., primary respondent memories).

Such appraisals may repeatedly recondition the traumatic me-

mory or other dysfunctional respondent-functional-appraisal

memory elements through higher-order language conditioning

(e.g., Kubany & Manke, 1995). Conversely, if respondent

memories or other respondent-functional-appraisal memory

elements are reevaluated (e.g., Davey, 1992), the dysfunctional

language and primary conditioning may be given an opportu-

nity to become inhibited.

Incompatible primary appraisal memories may be developed

during successful coping in response to primary negative events

or during participatory enjoyment in primary meaningful or

“positive” events. Incompatible secondary appraisal memories

are acquired during the retrieval of primary respondent-func-

tional-appraisal memories. Stimuli and responses that are en-

coded and appraised during the retrieval of primary respondent-

functional-appraisal memories become stored as secondary

appraisal memories. The encoding and storing of coping self-

efficacy appraisals includes appraisals of one’s perceived capa-

bility to manage one’s personal functioning and environmental

demands during the aftermath of traumatic events (Benight &

Bandura, 2004) and other types of distressing situations. Other

types of incompatible appraisal memories include appraisals of

lovability (that one deserves affection and caring), appraisals of

quality of life-ability (the ability to enjoy present situations, be

close to others etc.) and appraisals of achievement (achieving

important goals).

Consequence Memories

Dysfunctional primary consequence memories are encoded

and stored dysfunctional consequences that occurred during

primary events, behaviors and appraisals. Dysfunctional in-

trapersonal primary consequence memories consist of encoded

and stored dysfunctional consequences of behaviors and ap-

praisals enacted by the individual in primary events. Dysfunc-

tional intrapersonal secondary consequence memories are en-

coded and stored dysfunctional consequences of behaviors and

appraisals enacted by the individual during dysfunctional re-

spondent-functional-appraisal memory retrieval. Examples in-

clude dysfunctional negative reinforcement, higher-order lan-

guage conditioning of distressing emotions and intrusions and

self-initiated positive reinforcement of dysfunctional behaviors.

Dysfunctional interpersonal primary consequence memories

consist of encoded and stored dysfunctional responses of others

to an individual’s behaviors or appraisals (or lack thereof) dur-

ing or in close proximity to primary events. Encoded and stored

responses of others may include (a) reinforcements of dysfunc-

tional behaviors and appraisals, (b) punishments (e.g. being

harsh, critical and negligent) of functional behaviors and ap-

praisals, (c) non-contingent punishments, and (d) a lack of help

and support to the individual. The retrieval of dysfunctional

interpersonal consequence memories may be related to the

numbing symptoms alienation/distancing from others, less

enjoyment in appreciated activities (e.g. socially-related activ-

ties), and diminished ability to feel positive emotions (particu-

larly in relation to other people). Dysfunctional interpersonal

secondary consequence memories consist of encoded and

stored experiences of other people’s dysfunctional responses to

behaviors and appraisals enacted during dysfunctional respon-

dent-functional-appraisal memory retrieval. Other people’s

responses may include (a) reinforcements for dysfunctional

behaviors and appraisals (e.g., avoidance and faulty appraisals),

and (b) punishments for incompatible/functional behaviors and

realistic appraisals during dysfunctional respondent-functional-

appraisal memory retrieval. Such learning increases the like-

lihood of dysfunctional coping and decreases the likelihood of

engagement in functional behaviors and appraisals during dys-

functional respondent-functional-appraisal memory retrieval.

For example, if talking about a trauma, crying and displaying

tears or revealing negative thoughts and emotions leads to re-

peated negative reactions from others (Follette & Naugle, 2006),

such negative responses will be encoded and stored as dysfunc-

tional interpersonal consequence memories. Such consequence

memories may perpetuate PTSD and other psychopathology

symptoms and inhibit incompatible respondent-functional-

appraisal memories.

Incompatible primary consequence memories are developed

during the encoding and storing of reinforcing or absence-of-

punishing consequences to incompatible/functional behaviors

and appraisals during or in close proximity to primary events.

Incompatible intrapersonal primary consequence memories

include memories of self-enacted consequences whereas in-

compatible interpersonal primary consequence memories con-

sist of memories of consequences enacted by others. Incom-

patible secondary consequence memories constitute encoded

and stored experiences of intrapersonal and interpersonal rein-

forcements or absence-of-punishing consequences during in-

compatible and/or dysfunctional respondent-functional-ap-

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357

praisal memory retrieval. The retrieval of incompatible conse-

quence memories may increase the probability that the individ-

ual may engage in the reinforced or absence-of-punished be-

haviors.

Current Contingencies

Current behaviors and appraisals are influenced by currently

retrieved r espondent-functional-appraisal memory elements as

well as current contingencies. Table 1 and 2 illustrate respon-

dent and consequence memory elements that influence current

behaviors and appraisals in emotional and personality disorders.

It is hypothesized that currently enacted psychopathology-re-

lated appraisals and behaviors closely match retrieved psycho-

pathology-related primary and secondary appraisal and behav-

ioral memories.

Retrieval Triggers

Psychopathology-related retrieval triggers constitute encoded

stimuli and responses in current contingencies that match char-

acteristics of stored dysfunctional respondent-functional-ap-

praisal memory elements. Both the degree of similarity between

current encoding and stored respondent-functional-appraisal

memory elements, and the quality of encoding and storing may

determine the effectiveness of memory retrieval. Primary re-

trieval triggers closely match dysfunctional primary respon-

dent-functional-appraisal memory elements. In chronic PTSD

as a result of interpersonal violence a primary retrieval trigger

would constitute the encoding of a person or behavior in a cur-

rent situation that resembles a perpetrator on key physical cha-

racteristics or a violent behavior committed by a perpetrator.

The encoding and storing of such primary retrieval triggers may

through such a memory process start to function as a faulty

secondary discriminative memory of danger. Such memory

processes may through time more or less permanently modify

the original memory of the event and the perpetrator since the

encoded and stored retrieval triggers usually may have some

new characteristics that are dissimilar to the original stimuli

(Loftus, 2003). Secondary retrieval triggers match characteris-

tics of secondary respondent functional-appraisal memory ele-

ments and may become encoded and stored as additional sec-

ondary respondent-functional-appraisal memory elements. Again,

the respondent-functional-appraisal memory elements may

become modified due to some dissimilarity between currently

encoded and stored secondary retrieval triggers and existing

primary/secondary respondent-functional-appraisal memory

elements. Retrieved secondary respondent-functional-appraisal

memory elements may effectively retrieve primary respondent-

functional-appraisal memories if there are strong associations

between primary and secondary memory elements. Neutral

stimuli and responses that are encoded during respondent-

functional-appraisal memory retrieval may become associated

with the latter and start to function as secondary respondent-

functional- appraisal memory elements.

Incompatible primary retrieval triggers consist of encoded

stimuli and responses in current contingencies that match in-

compatible primary respondent-functional-appraisal memory

elements. Incompatible secondary retrieval triggers consist of

currently encoded stimuli and responses that match incompati-

ble secondary respondent-functional-appraisal memory ele-

ments. It is hypothesized that the same principles that may ap-

ply for psychopathology-related primary and secondary retriev-

al triggers are also generalizable to incompatible primary and

secondary retrieval triggers.

Behavioral Str ategies

Primary behavioral and cognitive strategies are enacted in

response to primary events. Coping strategies during negative

events include being passive, avoid or escape the situation or

trying to deal with/confront it (e.g., attack). Secondary behav-

ioral and cognitive strategies occur in response to dysfunctional

retrieval triggers and retrieved respondent-functional-appraisal

memory elements. Avoiding/escaping innocuous retrieval trig-

gers is dysfunctional whereas doing the same in response to

potentially harmful situations is functional. During the retrieval

of dysfunctional respondent-functional-appraisal memory ele-

ments dysfunctional behavioral strategies (overt and covert)

may be utilized in order to inhibit the retrieved memory.

Avoidance of retrieval triggers prevents a retrieval of dysfunc-

tional respondent-functional-appraisal memories. Behavioral

avoidance/escape may include excessive behavioral activation,

compulsive behaviors, planning ahead of how to avoid triggers,

escaping when confronted with triggers or during intrusions,

the use of alcohol/substances and safety behaviors. Cognitive

avoidance may include distraction, thought suppression, obses-

sive thinking, dissociation, actively trying not to think about

distressing memories, rumination and worrying.

Exposure to innocuous situations and conversations about

past negative events is objectively safe. The absence of nega-

tive consequences (e.g., decline in negative emotions, non-

occurrence of negative events) during functional coping (e.g.,

approaching innocuous stimuli) is encoded and stored as in-

compatible respondent-functional-appraisal memory elements

and may gain a function as inhibitors to dysfunctional respon-

dent-functional-appraisal memory elements. Behavioral and

cognitive avoidance, escape and safety behaviors prevent the

encoding of such incompatible experiences.

Behavioral activation in meaningful activities and behaviors

(e.g., Martell, Addis, & Jacobson, 2001) that elicit pleasurable

emotions and functional consequences are all encoded and

stored as incompatible respondent-functional-appraisal memory

elements. The retrieval of such memory elements may be util-

ized as inhibitors to dysfunctional respondent-functional-app-

raisal memory elements. Functional behavioral activation and

incompatible respondent-functional-appraisal memory retrieval

should map onto relevant problem areas or themes to the dys-

functional respondent-functional-appraisal memory elements in

order to function as effective inhibitors.

Current Appraisal s

Current appraisals are influenced by (a) what is encoded and

is occurring in current contingencies (e.g., present reinforce-

ments and punishments), (b) presently retrieved respondent-

functional-appraisal memory elements, (c) current behavioral

and cognitive coping/engagement, (d) consequences of the

former, and (e) cognitive elaboration and storing of the former.

Present encoding may be influenced by the nature of currently

retrieved respondent-functional-appraisal memory elements.

Faulty attributions of retrieved dysfunctional primary appraisal

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358

memories as due to currently encoded stimuli and responses is

encoded and stored as dysfunctional secondary appraisal mem-

ories. It is important to discriminate between current retrieval

triggers from retrieved dysfunctional respondent-function-al-

appraisal memory elements. Falsely predicting that current

retrieval triggers of retrieved incompatible/functional respon-

dent-functional-appraisal memories are indications that some-

thing similar is going to occur in the present situation will lead

to non-fulfilled expectations. Lack of such discrimination skills

may lead to disappointment or other negative responses.

Functional, incompatible or realistic appraisals may be de-

veloped or strengthened by (a) consciously encoding and stor-

ing aspects of current contingencies that are incompatible to

dysfunctional respondent-functional-appraisal memories, (b)

consciously retrieving incompatible respondent-functional-

appraisal memories, and (c) engaging in functional behavior-

al/cognitive responses (e.g., approaching innocuous stimuli,

engaging in meaningful activities, coping effectively with situ-

ations). Such behavioral engagements may contribute to the

development of incompatible/functional respondent-functional-

appraisal memories.

Current appraisals that are compatible with present realistic

circumstances are termed as realistic appraisals. Current ap-

praisals of correctly attributing symptoms to retrieved respon-

dent-functional-appraisal memory elements that have been

triggered by retrieval triggers may lead to a decrease in dys-

functional appraisals and increased functioning. New functional

appraisals may be developed, encoded and stored as secondary

appraisal memories that have the potential to inhibit dysfunc-

tional respondent-functional-appraisal memories.

The retrieval of dysfunctional respondent-functional-ap-

praisal memory elements may influence appraisals of current

retrieval triggers and coping responses. Dysfunctional beha-

vioral responses may be appraised as functional due to ap-

praised short-term advantages. Learning the realistic short- and

long- term implications of such coping responses may lead to

the development of functional appraisals of engaging in such

behaviors. The encoding and storing of functional appraisal

memories may guide the enactment of functional behaviors.

Reinforcement and Punis hme n t

Reinforcement and punishment constitute primarily intra-

and interpersonal stimuli and environmental events that func-

tion as consequences to behavioral responses and appraisals.

Reinforcement and punishment can be conscious or non-delib-

erate. Functional vs. dysfunctional behaviors and appraisals can

be reinforced or punished. For example, a child may subtly

support a mother’s avoidance behavior and a spouse “invalid-

date” emotional disclosure (Follette & Naugle, 2006). A critical,

harsh and hostile environment is related to a poorer outcome in

empirically supported treatments for PTSD (Tarrier, Sommer-

field, & Pilgrim, 1999). A social harshness respondent-func-

tional-app-raisal memory may thus develop. Social support may

function as reinforcement of functional or dysfunctional res-

ponses and appraisals. If the function of social support is to

shut down the retrieval of dysfunctional respondent-functional-

appraisal memories it may be dysfunctional since it prohibits

the possibility of inhibiting dysfunctional respondent-func-

tional-appraisal memories. Social support-seeking behaviors

may be punished or reinforced. Punishments for social-support

seeking behaviors may be due to discrimination deficits of from

who to seek social support (Follette & Naugle, 2006). Social

support may be sought in order to suppress or avoid the re-

trieval of dysfunctional respondent-functional-appraisal memo-

ries (i.e., safety behaviors). Reinforcing and punishing stimuli

are encoded and stored as reinforcing vs. punishing conse-

quence memories.

Discriminative Stim uli

Discriminative stimuli consist of external or internal stimuli

whose function is to signal (a) the consequences to responses

and/or appraisals, and (b) what will happen next in specific

situations. Stimuli that function as faulty discriminative stimuli

for the occurrence of negative events (e.g., punishments) do so

due to the retrieval of dysfunctional respondent-functional-

appraisal memories. Realistic predictive functions of discrimin-

ative stimuli for negative occurrences increases the chances of

functional coping since it may provide an increased possibility

for preparation and prevention. The encoding of stimuli or res-

ponses that signal the occurrence of meaningful or pleasurable

events due to respondent-functional-appraisal memory retrieval

may constitute realistic or unrealistic predictions. Faulty pre-

dictions of pleasurable/meaningful events may lead to positive

punishment (e.g., non-fulfilled positive predictions). Correct

predictions of pleasurable/meaningful events lead to positive

reinforcement. Discriminative stimuli, enacted behaviors (or a

lack thereof) and its consequences are encoded and stored as

respondent-functional-appraisal memory elements.

PTSD Symptoms, Associated Features and

Mechani sms

Intrusions in chronic PTSD are conceptualized as follows.

The encoding of current retrieval triggers leads to the retrieval

of trauma-related respondent-functional-appraisal memories.

Primary respondent-functional-appraisal memories of a trau-

matic event are hypothesized to generate the most distressing

intrusions (flashbacks, severe nightmares, severe physiological,

emotional and pain responses) and consist of the following

encoded and stored elements (see also Figure 1):

● Central details of the event (primary respondent stimuli

memor ie s)

● Emotional, physiological and pain responses experienced

during the gist of the trauma (primary respondent response

memor ie s)

● Appraisals during the gist of the trauma (primary appraisal

memor ie s)

● Behavioral responses enacted during the gist of the trauma

(primary behavioral response memories)

● Consequences during and/or soon after the trauma (pri-

mary consequence memories)

The possibly more common intrusions in PTSD may consti-

tute secondary respondent-functional-appraisal memories (e.g.,

Ehlers et al., 2002). These memories are associated with imme-

diate pre-trauma situations and peripheral stimuli that were

encoded in close proximity to or during the trauma. The re-

trieval of such memories function as faulty warning signals of

threat. The continuous on-going threat experience in chronic

PTSD is due to an on-going partial-full retrieval of trau-

ma-related respondent- functional-appraisal memories. Re-

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trieved trauma-related respondent-functional-appraisal memo-

ries lead to/influence:

● Painful emotional, physiological and bodily respondent

responses

● Spontaneous sensory-based intrusions of the trauma and

peripheral stimuli

● Faulty current appraisals of (a) the dangerousness of pres-

ently encoded stimuli and responses, (b) other people as non-

trustworthy, non-understanding, non-safe, (c) self as lacking in

self-efficacy and other negative appraisals (e.g., crazy, irre-

mediably wounded, non-functional), and (d) avoidance and

escape from retrieval triggers as functional

● Dysfunctional avoidance of retrieval triggers that prevents

the retrieval of trauma-related respondent-functional-appraisal

memor ie s

● Dysfunctional escape from trauma-related retrieval triggers

or safety behaviors whose function is to shut down retrieved

trauma-related respondent-functional-appraisal memories

● Inhibition of (a) incompatible currently encoded stimuli

and responses, and (b) retrieved incompatible respondent-func-

tional-appraisal memories.

The fragmentation of traumatic memories in PTSD may be

explained by the initial retrieval and an immediate shutdown of

excessively distressing respondent-functional-appraisal memo-

ries due to automated or conscious avoidance behaviors. Com-

plementarily, it may be due to an automatic biological process

that protects against overwhelming emotional and other types

of pain.

Psychogenic amnesia may constitute a temporary inaccessi-

bility or shutdown of trauma-related respondent-functional-

appraisal memories. This may be a result of initially successful

conscious avoidances of dysfunctional respondent-functional-

appraisal memory retrieval that has become automatic, to en-

coded and stored peritraumatic dissociation, and or current

dysfunctional coping that blocks the access to trauma-related

respondent-functional-appraisal memory elements.

The “here and now” quality of intrusions may be explained

by the retrieval of primary respondent memories (e.g., flash-

backs). When primary respondent memories are retrieved the

currently encoded stimuli and responses may be appraised as a

current threat and be preferentially attended to (i.e., attentional

bias).

Numbing symptoms in chronic PTSD may be conceptualized

as: (a) dysfunctional behavioral response memories of re-

stricted emotional expression in interpersonal situations (Miller

& Litz, 2004; Roemer et al., 2001), (b) a lack of reinforcing

activities as proposed in behavioral theories of depression (e.g.,

Lewinsohn, Hoberman, Teri, & Hautzinger, 1985) that is the

long-term consequence of the avoidance of retrieval triggers, (c)

inhibition of incompatible memories by trauma intrusions

(Amdur, Larsen, & Liberzon, 2000; Litz et al., 2000; Miller &

Litz, 2004; Spahic-Mihajlovic, Crayton, & Neafsey, 2005), and

(d) dysfunctional consequence memories of social punishment

for expressing negative emotions or the trauma (Follette &

Naugle, 2006).

Hyperarousal symptoms are due to a continuous partial re-

trieval of trauma-related respondent-functional-appraisal me-

mories that emotionally drains the individual of cognitive re-

sources and leads to a heightened physiological baseline (e.g.,

Foa, Riggs, & Gershuny, 1995).

Dysfunctional pretrauma, trauma and posttrauma respondent-

functional-appraisal memories may retrieve and potentiate each

other in each direction and lead to comorbid psychopathology

symptoms (see Table 1 and 2). Dysfunctional respondent-func-

tional-appraisal memories that developed in early life may be-

come more or less strongly interconnected with dysfunctional

respondent-functional-appraisal memories formed in adoles-

cence and/or adulthood and generate PTSD symptoms and co-

morbid psychopathology.

Peritraumatic dissociation may be conceptualized as an au-

tomatic cognitive distancing response during the trauma whose

function is to limit the pain and distress during the event. En-

coded and stored peritraumatic dissociation may be retrieved

during the trauma sequel and generate automatic dissociative

respo nses.

Ruminations and worrisome thinking are characterized by a

negative repetitive verbal/semantic thinking that includes both

avoidant functions (e.g., Barlow, 2002; Watkins, 2008) and

dysfunctional meanings. One faulty predictive function is the

prevention of imagined catastrophes. Ruminative and worri-

some thinking can be modeled by others and stored as dysfunc-

tional behavioral response and/or appraisal memories.

Unorganized trauma memories may be due to (a) fragmen-

tary retrieval of trauma-related respondent-functional-appraisal

memories, (b) the retrieval of dysfunctional behavioral response

memories that blocks the access to most other respondent-

functional-appraisal memory elements, and (c) a lack of inhi-

bition of trauma-related respondent-functional-appraisal memo-

ries by functional/ incompatible respondent-functional-apprais-

al memories.

Since the retrieval of dysfunctional appraisal memories may

be accompanied by the retrieval of respondent-functional

memory elements, negative thoughts may be experienced as

“emotional” and “real”. This may explain the automaticity and

strong emotions associated with some negative thoughts.

The inhibition of incompatible respondent-functional-ap-

praisal memories by trauma-related respondent-functional-ap-

praisal memories enables retrieval triggers to automatically

retrieve dysfunctional respondent-functional-appraisal memory

elements. Thus, retrieved trauma-related respondent-functional-

appraisal memories may be experienced as occurring in the

present rather than as a past event since there is no temporary

access to incompatible respondent-functional-appraisal me-

mories.

Anniversary reactions can be explained as anniversary dates,

occasions and events that function as unique retrieval triggers

of dysfunctional respondent-functional-appraisal memories.

Other psychopathology disorders may be conceptualized in

the same manner as PTSD in terms of the behavioral-cognitive

inhibition theory (e.g., see Tables 1 and 2).

Respondent-F unctional-Appraisal Memory

Associative Ne t w orks

Respondent-functional-appraisal memory associative net-

works consist of multiple respondent-functional- appraisal me-

mories that are associated with each other and that may more or

less mutually inhibit or reinforce each other (see Figure 2). A

dysfunctional respondent-functional-appraisal memory associa-

tive network is characterized by the following:

● Associations between different dysfunctional respondent-

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Figure 2.

Illustration of (a) a very dysfunctional respondent-functional-appraisal

memory associative network (RFAM-AN) in which extremely strong

dysfunctional respondent-functional-appraisal memories (RFAMs) have

inhibited incompatible RFAMs so that the latter have become very

weak, (b) a moderately dysfunctional RFAM-AN in which moderately

dysfunctional RFAMs have inhibited incompatible RFAMs so that the

latter have become moderately weak (and/or vice versa), and (c) a very

strong incompatible RFAM-AN consisting of very strong incompatible

RFAMs that have inhibited dysfunctional RFAMs so that the latter have

become very weak.

functional-appraisal memories are more or less strong.

● Associations between dysfunctional respondent-functional-

appraisal memories may be stronger than associations between

incompatible respondent-functional-appraisal memories

● Dysfunctional respondent-functional-appraisal memory

associative networks contain excessively inhibited incompatible

respondent-functional-appraisal memories.

If dysfunctional respondent-functional-appraisal memories

are strongly interconnected, the retrieval of one type of dys-

functional memory should lead to the retrieval of other dys-

functional memories. If correct, such associations may explain

why a successful treatment of one axis-1 disorder may lead to

an automatic improvement in comorbid axis-1 disorders. If

associations between different dysfunctional respondent-func-

tional-appraisal memories are weak, retrieval of one memory

will less likely lead to the retrieval of other memories, or to an

automatic improvement of disorders that have not been targeted

in treatment. Strong associations between dysfunctional re-

spondent-functional-appraisal memories should lead to an easy

and automatic retrieval of multiple memories, especially if

associations between incompatible respondent-functional-ap-

praisal memories are weak.

Dysfunctional respondent-functional-appraisal memories may

inhibit or reinforce each other. Depressive-related respondent-

functional-appraisal memories may reinforce other depressive-

related respondent-functional-appraisal memories. Fear-related

respondent-functional-appraisal memories may reinforce other

fear-related respondent-functional-appraisal memories. It may

be an interesting question whether depressive-related respon-

dent-functional-appraisal memories may temporarily inhibit

anxiety-related respondent-functional-appraisal memories (e.g.,

Mogg, Bradley, Williams, & Mathews, 1993). If so, when de-

pressive-related respondent-functional-appraisal memories be-

come inhibited anxiety-related respondent-functional-appraisal

memories may become more easily accessible for retrieval.

Dysfunctional respondent-functional-appraisal memories may

overlap in certain characteristics with incompatible/functional

respondent-functional-appraisal memories. For example, en-

coded and stored salient physical characteristics of a perpetrator

may be similar to physical characteristics of a significant per-

son. Memories or currently encoded aspects of such a signifi-

cant other may be a retrieval trigger for memories of a perpe-

trator and a traumatic event. Another example is that for rape

victims with chronic PTSD sexual activities with a partner may

function as a retrieval trigger of distressing rape trauma memo-

ries.

Dysfunctional respondent-functional-appraisal memories in

complex PTSD may contain complex memories of (a) sexual

and physical abuse committed by a parent or caretaker, (b) the

need for love and dependence from the same person, and (c) an

excessive deprivation in essential emotional, social and other

important human needs (Kohlenberg et al., 2006).

Respondent-functional-appraisal memories in PTSD as a re-

sult of type 1 vs. type 2 traumatic events (Terr, 1991) may dif-

fer considerably. In PTSD as a result of type 1 traumas dys-

functional respondent-functional-appraisal memory associative

networks may more likely be characterized by moderately dys-

functional and moderately inhibited incompatible/ functional

respondent-functional-appraisal memories (see upper right part

of figure 2). In PTSD as a result of type 2 traumas dysfunc-

tional respondent-functional-appraisal memory associative

networks may more likely to be characterized by extremely

dysfunctional respondent-functional-appraisal memories and

excessively inhibited incompatible respondent-functional-ap-

praisal memories (see upper left part of Figure 2).

Retrieved dysfunctional respondent-functional- appraisal me-

mories vary in the amount of distress they elicit. Primary me-

mories ought most usually to elicit the most distressing symp-

toms, be more non-conscious and be more difficult to deliber-

ately retrieve than secondary respondent-functional-appraisal

memories. Secondary memories ought to be more verbally

accessible and easy to deliberately retrieve.

Therapeutic Inhibiti on

Various types of incompatible respondent-functional- ap-

praisal memories, behaviors and appraisals are illustrated in

table 3. A more extensive focus is made on imagery-related

incompatible respondent-functional-appraisal memories that

constitute (1) encoded and stored life events incompatible to the

trauma in several problem areas and/or central themes, and (2)

modified trauma-related imagery by rescripting techniques on

the basis of increased self-efficacy and nurturing. Other types

of incompatible respondent-functional-appraisal memories are

more summarily presented in table 3. Incompatible respon-

dent-functional-appraisal memory elements may be retrieved in

order to (a) inhibit dysfunctional respondent-functional-ap-

praisal memories, (b) motivate functional behavioral coping,

and/or (c) instigate more functional appraisals. Functional be-

havioral coping and functional re-appraisals in response to re-

trieval triggers of dysfunctional respondent-functional-appraisal

memories may lead to the development of incompatible re-

spondent-functional- appraisal memories.

A distinction is made between within respondent-functional-

appraisal memory inhibition and between respondent-func-

tional-appraisal memory inhibition. In within respondent-func-

tional-appraisal memory inhibition incompatible memory ele-

ments within respondent-f un cti ona l-appraisal memories are

developed through the encoding and storing of: (a) incompati-

ble/functional behaviors and consequences in relation to the

negative predictions that are made during dysfunctional

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Table 3.

Examples of incompatible respondent-functional-appraisal memories (RFAMs), appraisals and behavioral responses.

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respondent-functional-appraisal memory retrieval, (b) the ab-

sence of excessively distressing emotional, physiological and

pain responses during the retrieval of dysfunctional respon-

dent-functional- appraisal memory elements, and (c) realistic

re-appraisals of current contingencies and retrieved psychopa-

thology-related respondent-functional-appraisal memories.

In between respondent-functional-appraisal memory inhibit-

tion incompatible respondent-functional- appraisal memories

that map onto central problem areas of dysfunctional respon-

dent-functional-appraisal memories are utilized as inhibitors to

the latter. In PTSD respondent-functional-appraisal memories

that are associated with a high degree of safety, trust, intimacy,

control and self-worth are incompatible to the high degree of

danger, lack of trust and intimacy, low control and low self-

worth that are found in this disorder (see Resick & Schnicke,

1993 for these problem areas). Between respondent-functional-

appraisal memory inhibition can be accomplished by retrieving

primary respondent-functional-appraisal memories of safety,

trust, intimacy, control and self-worth in the same circum-

stances as dysfunctional respondent-functional-appraisal me-

mories are retrieved. In addition, behavioral activation in rele-

vant problem areas may lead to the encoding and storing of new

relevant respondent-functional-appraisal memories. Another

conceptualization of relevant problem areas includes respon-

dent-functional-appraisal memories of activities and/or events

associated with pleasure, nurturing and mastery. Pleasure and

nurturing are incompatible to numbing, depressive symptoms

and a lack of self-worth. Mastery (e.g., Benight & Bandura,

2004) is incompatible to a lack of control and helplessness of-

ten found in traumatized individuals and other psychopathology

disorders. Paunović (1999, 2002, 2003) illustrates in several

case studies how incompatible respondent and consequence

memories can be utilized in order to counter numbing symp-

toms in PTSD and inhibit primary trauma-related respondent

memories. Furthermore, behavioral activation in life areas that

may provide pleasure, nurturing and self-efficacy can be en-

coded and stored as incompatible respondent-functional-ap-

praisal memories. Such memories may in turn be utilized or

function as effective inhibitors to dysfunctional respondent-

functional-appraisal memories.

Recovery from psychopathology symptoms may require the

fulfillment of the following conditions: (a) the retrieval of dys-

functional respondent-functional-appraisal memories, (b) the

retrieval of incompatible respondent-functional-appraisal me-

mories and/or (c) the encoding and storing of incompatible

current stimuli, responses and appraisals in the same circum-

stances as retrieved dysfunctional respondent-functional-ap-

praisal memories. The encoded and stored incompatible stimuli,

responses and appraisals become incorporated into the dysfunc-

tional respondent-functional-appraisal memory. If the incom-

patible memory elements are strong enough they may be able to

inhibit the dysfunctional memory elements. Optimal inhibition

may not be achieved if (a) dysfunctional respondent-functional-

appraisal memories are incompletely retrieved, (b) incompati-

ble respondent-functional-appraisal memories are not strong

enough, (c) incompatible respondent-functional-appraisal me m-

ories don’t map onto all relevant problem areas, and/or (d) in-

compatible current contingencies and associated behaviors and

appraisals are not properly encoded and stored.

Recovery from comorbid psychopathology may occur under

the following conditions: (a) retrieval of the dysfunctional re-

spondent-functional-appraisal memory network, (b) retrieval of

the dysfunctional network in the same circumstances as when

incompatible respondent-functional-appraisal memory net-

works are retrieved, or current incompatible contingencies (e.g.,

functional behaviors, appraisals etc.) that map onto dysfunc-

tional respondent-functional-appraisal memory networks are

encoded, stored and incorporated into the dysfunctional mem-

ory network.

One may hypothesize at least four possible end-point out-

comes of attempted therapeutic inhibition. First, complete inhi-

bition which constitutes an optimal and generalized inhibition

to all primary dysfunctional respondent-functional-appraisal

memories. Second, chronic dysfunctional respondent-functional-

appraisal memory retrieval where therapeutic inhibition has not

been accomplished, dysfunctional respondent-functional-ap-

praisal memories are constantly retrieved and generate severe

psychopathology symptoms. Third, an excessive avoidance of

dysfunctional respondent-functional-appraisal memory retrie-

val. Here the encoding of retrieval triggers is excessively

avoided, and a retrieval of dysfunctional respondent-functional-

appraisal memories leads to an immediate and automatic shut-

down of dysfunctional memory elements. Fourth, excessively

negative current appraisals may continuously reinforce dys-

functional respondent-functional-appraisal memories.

Dis cussion

Examples of testable hypotheses that can be deduced from

the model are the following. Fi rst , dysfunctional respondent-

functional-appraisal memory elements may be measured by

instruments that tap onto faulty/functional appraisals and pre-

dictions, distressing vs. incompatible respondent and operant

responses, reinforcing and punishing consequences and dys-

functional vs. functional contingencies. Groups that fulfill cri-

teria for various types of disorders should be compared to

groups without the respective disorder on corresponding meas-

ures. In PTSD a group that have been traumatized but don’t

fulfill the criteria for PTSD should also be included in order to

determine the impact of the event per see. Second, the inhibit-

tion of dysfunctional respondent-functional-appraisal memories

can be accomplished through various routes of inhibition: (a)

the inhibition of dysfunctional respondent memories by in-

compatible respondent memories, (b) the inhibition of faulty

appraisal memories by realistic appraisal memories, (c) the

inhibition of dysfunctional behavioral response memories by

functional behavioral response memories (d) the inhibition of

faulty discriminative memories by realistic discriminative me-

mories, (e) the inhibition of dysfunctional punishing/reinforcing

consequence memories by functional/incompatible consequence

memories, (f) the inhibition of dysfunctional respondent-func-

tional-appraisal memories through the route of currently en-

coded and stored incompatible current contingencies, and (g)

the inhibition of one type of dysfunctional respondent-func-

tional-appraisal memory element by another type of incompati-

ble respondent-functional-appraisal memory element. Measures

that tap various types of respondent-functional-appraisal mem-

ory elements should be administered before and after a treat-

ment and at follow-up in order to assess the degree of inhibition.

In addition, it may be important to administer key measures

N. PAUNOVIĆ

363

during a treatment at various points in time in order to deter-

mine when the inhibition takes place and how the improvement

curve looks like through time. In a treatment group measures

that tap onto dysfunctional respondent-functional-appraisal me-

mory elements should diminish significantly from pre to post-

treatment as well as measures that tap onto psychopathology

symptoms. In a randomly assigned wait control condition such

improvements should not occur. Third, the more dysfunctional

respondent-functional-appraisal memory elements are, the more

likely they are to influence current psychopathology symptoms,

appraisals and behaviors. A psychopathology group with sig-

nificantly more dysfunctional respondent-functional-appraisal

memory elements should display significantly more psychopa-

thology symptoms and ought to be more difficult to treat. The

latter may be indexed by the need for more sessions in order to

achieve a successful treatment outcome and less improvement

in therapy. In addition, there might be a need for a broader

treatment strategy that focus on all the treatment needs (e.g., on

all dysfunctional respondent-functional-appraisal memory ele-

ments). Fourth, the more distressing and serious life events an

individual has experienced, the more likely it may be that dys-

functional respondent-functional-appraisal memories may de-

veloped. The seriousness of distressing life events may be

measured by developing measures that tap onto the degree of

exposure to various types of distressing life events. In PTSD

such measures have been developed. However, to the best of

the author’s knowledge such measures don’t exist in other psy-

chopathology disorders. In addition, measures that tap onto

psychological vulnerabilities may be utilized. Corresponding

measures can be developed in order to tap various degrees and

amounts of incompatible or functional life events, as well as

degrees of emotional engagement into such encoded and stored

experiences. Such experiences in interaction with an individ-

ual’s responses to such events may function as protective fac-

tors if highly functional or incompatible respondent-function-

al-appraisal memories have been developed.

Evidence-based cognitive-behavioral therapies may primarily

exert their efficacy through different routes of inhibition. In in

vivo, imaginal and interoceptive exposure incompatible re-

spondent-functional-appraisal memories may mainly develop

through (a) the encoding and storing of diminished physiologi-

cal/emotional reactions during exposure, (b) the encoding and

storing of the absence of imagined negative consequences dur-

ing exposure, and (c) the retrieval of functional/incompatible

respondent-functional-appraisal memory elements. In cogni-

tive therapy the primary aim may be to inhibit faulty appraisal

memories by developing new functional/incompatible respon-

dent-functional-appraisal memories. When faulty primary ap-

praisal memories and other dysfunctional respondent-func-

tional-appraisal memories are retrieved central re-appraisals may

occur due to (a) the encoding and storing of incompatible cur-

rent contingencies, and (b) the retrieval of incompatible re-

spondent-functional-appraisal memory elements. Current real-

istic current contingencies and functional appraisals become

encoded and stored in memory, and these memories may start

to function as incompatible respondent-functional-appraisal

memory elements. In imagery rescripting a primary aim is to

rescript two types of outcomes in memories of primary negative

events: (a) from non-controllable distressing events to a mas-

tery of the negative situations, and (b) from post-event sequels

during which there was a lack of social support or nurturing to

the nurturing of the self.

Young’s schema therapy model for personality disorders

(Young et al., 2003) is re-conceptualized in accordance with the

behavioral-cognitive inhibition theory. Primarily, schemas from

Youngs model are behaviorally formulated (see Table 2). One

important question might be how to categorize the various

types of encoded and stored events, related emotional responses

and other memory elements in terms of various degrees of in-

tensity, frequency and durability. Young’s maladaptive coping

responses are conceptualized as dysfunctional behavioral re-

sponses to retrieval triggers and retrieved respondent-func-

tional-appraisal memories.

Brewin (2006) contrasts the accommodation model to the ac-

tivation-deactivation model. According to the accommodation

model therapy modifies structures in memory that give rise to

negative beliefs (e.g., Beck et al., 1985; Foa et al., 1989). On

the contrary, the activation-deactivation model (Brewin, 2006)

assumes that effective therapy is due to the deactivation or

blocking of negative memories and the activation and creation

of positive memories. The key element of effective CBT is that

positive memories should win the retrieval competition over

negative memories. The behavioral-cognitive inhibition theory

is compatible with both of these models. First, dysfunctional

respondent-functional-appraisal memories must be retrieved.

Second, dysfunctional respondent-functional-appraisal memo-

ries must be inhibited by incompatible or functional respon-

dent-functional-appraisal memories or encoded and stored cur-

rent contingencies. Functional inhibition is accomplished when

the retrieval of incompatible respondent-functional-appraisal

memories take precedence over psychopathology-related re-

trieved respondent-functional-appraisal memories. Ideally, in-

compatible respondent-functional-appraisal memories should

dominate over dysfunctional respondent-functional-appraisal

memories. This is in line with the activation-deactivation model.

This in turn must be associated with a change of the respon-

dent-functional-appraisal memory network structure that is in

accordance with the accommodation model.

In the behavioral-cognitive inhibition theory appraisals are

conceptualized both in terms of (a) appraisal memories some-

what similar to the “meaning representations” in the emotional

processing theory (e.g. Foa & Kozak, 1986; Foa & Rothbaum,

1998; Foa, Steketee, & Rothbaum, 1989), and (b) as current

appraisals as in Ehlers and Clarks cognitive theory of PTSD

(Ehlers & Clark, 2000). In addition, the behavioral-cognitive

inhibition theory conceptualizes respondent and operant me-

chanisms both in terms of dysfunctional memories and current

contingencies that bi-directionally influence each other.

The “nature of” dysfunctional vs. incompatible respondent-

functional-appraisal memories and memory networks presented

in Figure 2 have been made primarily for illustrational purposes.

The “exact nature of” respondent-functional-appraisal memo-

ries and memory networks in various types of psychopathology

disorders is an empirical question. In addition, the two-dimen-

sionality of the presented figure may not optimally illustrate the

interdependence between various types of respondent-func-

tional-appraisal memory elements and memories.

Primary dysfunctional respondent-functional-appraisal mem-

ory elements may become more or less permanently modified

due to the encoding and storing of similar postevent stimuli and

N. PAUNOVIĆ

364

responses that to a certain degree don’t match the originally

encoded and stored features. Original memories of real life

events can be distorted by post-event stimuli such as faulty

police investigatory procedures that may create new features

into the original memories (Loftus, 2003). Distorted memories

may still elicit the same or similar psychopathology symptoms

that may need to be treated.

Some emotions presented in Table 2 (e.g., emotions labeled

as “loneliness” and “abandonment”) may constitute question-

able concepts of emotions. They may not match conceptualiza-

tions of primary (innate) or common secondary emotions (ap-

praisal-driven). However, such concepts may be adequate in

order to tap some emotional responses to certain types of dis-

tressing life events.

Some individuals may have few existing incompatible or

functional respondent-functional-appraisal memories due to

long-lasting life experiences of deprivation and punishments.

Such individuals may be particularly prone to develop person-

ality disorders. In such cases longer-term therapy is needed that

focuses on providing incompatible experiences that at least

partially fulfils arrested needs and counters the effects of pun-

ishments. Over time, strong enough incompatible respondent-

functional-appraisal memories may be developed that are capa-

ble to inhibit dysfunctional respondent-functional-appraisal

memor ie s.

One potentially interesting question is whether different

types of respondent-functional-appraisal memories can be ca-

tegorized into various types of psychological vulnerabilities.

Not necessarily in accordance with a dichotomous categoriza-

tion of generalized vs specific psychological vulnerabilities

(e.g., Barlow, 2002). Another important question is what types

of psychological vulnerabilities, and/or constellations of such

vulnerabilities, may lead to the development of specific types of

or combinations of psychopathology disorders. A third poten-

tially important question is how to conceptualize biological

vulnerability.

To summarize, the main strengths of the behavioral-cognitive

inhibition theory is that (a) it comprehensively accounts for

comorbidity, numbing symptoms and other PTSD-related

symptomatology, (b) it may be able to explain the development

and maintenance of both single psychopathology disorders as

well as a broad range of psychopathology disorders, (c) it is

parsimonious in relation to its broad applicability, and (d) it

solves the overdetermination problem.

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