An examination of multiple components of emotional processing theory as predictors of symptom change in prolonged exposure for posttraumatic stress disorder

Abstract

Prolonged exposure (PE) is an empirically supported treatment for adult posttraumatic stress disorder (PTSD). The foundation of PE, emotional processing theory (EPT), posits that PTSD is maintained by a pathological network of associations among stimuli, responses, and meaning. Therapeutic change occurs when the network is activated and new information is integrated, which weakens the pathological associations and facilitates learning of more adaptive associations. Studies of EPT have focused on a limited number of indicators of emotional processing, and some findings have been mixed. A more thorough approach to studying EPT is proposed, using observational methods to measure multiple components of EPT in one trial. These include: 1) conditions that facilitate clients' learning and processing of new information, 2) weakening of old, pathological learning, and 3) strengthening of new, more adaptive learning. Participants were 42 adults with PTSD receiving PE as part of an ongoing trial. Video recordings of sessions were coded to capture the components of EPT and to examine how they relate to each other and to change in PTSD symptoms. Facilitators of processing were largely uncorrelated with measures of processing, and each group of variables did not predict unique variance in PTSD symptom improvement. Two individual variables emerged as predictors of symptom improvement: lower cognitive rigidity and a greater decrease in negative trauma-related cognitions across sessions. Findings contribute to growing evidence suggesting the importance of cognitive change as part of emotional processing, beyond activation and reduction in negative emotions. Implications for measurement of EPT and for clinical practice are discussed.