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The Role of Thought Suppression in Posttraumatic Stress Disorder

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The Role of Thought Suppression in Posttraumatic Stress Disorder The Role of Thought Suppression in Posttraumatic Stress Disorder Jillian C. Shipherd, J. Gayle Beck State University of New York at Buffalo nosis of chronic PTSD. Prevalence rates for chronic Thirty motor vehicle accident (MVA) survivors with PTSD PTSD vary between studies and trauma type. In a and 25 without PTSD completed a trauma-related thought- review of the literature following one type of trauma, suppression task. Both groups successfully suppressed trauma- it was estimated that between 9% and 40% of sur- related thoughts, followed by a rebound effect for the PTSD vivors of motor vehicle accidents develop chronic group, and no rebound effect for the no-PTSD group, in a PTSD (Blanchard & Hickling, 1997). Clearly, an replication of previous work (Shipherd & Beck, 1999). Addi- understanding of individual differences that influ- tionally, a personally relevant, neutral thought-suppression ence progression into a more entrenched patholog- task was included to examine the generalizability of thought ical state would be beneficial. The current study suppression in PTSD participants. The PTSD group was able was designed to examine one such factor, specifi- to suppress neutral thoughts without a rebound effect, sug- cally thought suppression. gesting that increases in suppressed thoughts are specific to The theoretical literature provides a conceptual trauma-relevant cognitions in individuals with PTSD. The framework for understanding the potentially im- potential role of thought suppression as a maintaining factor portant role of thought suppression in the main- for reexperiencing symptoms of PTSD is discussed. tenance of PTSD. Information processing theory hypothesizes that traumatic experiences remain in active memory, accompanied by a drive to incorpo- rate this information into existing mental represen- Following a traumatic event, it can be tations (Horowitz, 1976; Lang, 1977). The theory predicted that some individuals will experience dis- predicts that intrusive thoughts will result until the tress and symptoms of posttraumatic stress disor- material is fully assimilated into the individual’s der (PTSD; American Psychiatric Association [APA], conceptual memory. Thus, it is possible that allow- 1994). It has been documented that these symp- ing intrusive thoughts to occur without censure may toms tend to decrease naturally during the 3 months facilitate recovery, according to this theory, whereas immediately following a trauma (Ehlers, Mayou, & thought suppression may prevent re-experiencing Bryant, 1998; Rothbaum, Foa, Riggs, Murdock, symptoms from remitting (Horowitz, 1976; Lang, & Walsh, 1992). Unfortunately, some trauma sur- 1977). Support for this hypothesis can be found in vivors continue to experience symptoms and dis- the empirical literature. For example, the use of tress beyond the first 3 months, leading to a diag- suppression as a coping strategy following trauma was found to predict psychological distress in survey Jillian C. Shipherd, Ph.D., is now at the National Center for studies involving both adults and children (Aaron, PTSD–Women’s Health Sciences Division, Boston VA Healthcare System, and Boston University School of Medicine. Zagul, & Emery, 1999; Amir et al., 1997; Ehlers et We would like to express our appreciation to Berglind Gud- al., 1998; Morgan, Mathews, & Winton, 1995). mundsdottir and Hollie Raynor for their assistance conducting These studies found that survivors who attempted to diagnostic interviews for this project. Similarly, we would like to thank Jennifer Gorham and Chrissy Roth for their assistance in the avoid aversive memories by suppressing intrusive coding of thought-listing data. Further, the first author would like thoughts endured more reexperiencing symptoms. to thank her dissertation committee, who approved and supported These findings support the hypothesis that deliberate this project. This study was funded by the Graduate Student Association of thought suppression facilitates the maintenance of the State University of New York at Buffalo through the Mark Dia- these symptoms, a supposition that has been dis- mond Research Award. cussed by several authors (Amir et al., 1997; Gold & Address correspondence to Dr. Jillian C. Shipherd, National Center for PTSD, Women’s Health Sciences Division (116B-3), VA Wegner, 1995; Purdon, 1999; Purdon & Clark, 2000; Medical Center, 150 South Huntington Avenue, Boston, MA 02130; Steil & Ehlers, 2000; Trinder & Salkovskis, 1994). e-mail; [email protected]. The paradigm developed by Wegner and colleagues BEHAVIOR THERAPY 36, 277–287, 2005 (Wegner, Schneider, Carter, & White, 1987) has be- 005-7894/05/0277–0287$1.00/0 come a popular tool for examining the effects of Copyright 2005 by Association for Advancement of Behavior Therapy All rights for reproduction in any form reserved. deliberate thought suppression. In studies using 278 shipherd & beck this paradigm, half of the participants suppressed needed to understand the role of thought suppres- target thoughts (e.g., thoughts about a white bear) sion in various disorders. and the remaining participants simply monitored With regard to studying trauma recovery, several their thoughts. Following this initial period, all studies have used analogue populations exposed to participants monitored their thoughts without stressful films to examine thought suppression. In suppressing any specific thoughts. In this way, the these studies, a rebound effect has been demon- immediate and delayed effects of suppressing strated (Davies & Clark, 1998; Harvey & Bryant thoughts were examined. Wegner’s theory (Weg- 1998b; McNally & Riccardi, 1996). These studies ner, 1989) of the ironic effects of thought suppres- provided the first evidence for the importance of sion is the predominant theoretical model for ex- the rebound effect in trauma recovery. Further ex- plaining the process of suppression. This theory ploration of thought suppression has been under- posits that thought suppression can occur by shift- taken with samples of trauma survivors (Harvey & ing attention to an irrelevant stimulus through a Bryant, 1998a; Shipherd & Beck, 1999). For exam- two-level system (Wegner, 1994). One part of this ple, Harvey and Bryant’s (1998a) study of thought system is an intentional and effort-intensive “oper- suppression in newly traumatized individuals re- ating process,” whereby the participant is seeking vealed that participants demonstrated a rebound distracting stimuli. Simultaneously, there also is an effect. Specifically, in the immediate aftermath of a unconscious and automatic “monitoring process” traumatic motor vehicle accident, suppression of trau- that is vigilant for the suppressed material. Through matic material led to a resurgence of these thoughts the use of this two-part system, distracters can be- in individuals with and without Acute Stress Disor- come powerful cues for the return of suppressed der (ASD). However, the results did not argue for material and thought suppression inevitably leads specificity of thought rebound in ASD, a finding to an increase in the frequency of suppressed mate- that may have been attributable to the recency of rial. Thus, the thought suppression theory is con- the trauma. In order to explore the role of thought sistent with information processing theories for un- suppression in chronic PTSD, Shipherd and Beck derstanding PTSD, as the role of powerful cues for (1999) compared women with and without PTSD intrusive thoughts is well-known in this disorder. following sexual assault (average 6 years post- In support of this theory, two paradoxical effects assault). Sexual assault survivors with chronic PTSD have been documented when measuring target demonstrated a rebound effect with trauma-related thoughts in college samples (e.g., Clark, Ball, & Pape, thoughts following suppression whereas the sur- 1991; Lavy & van den Hout, 1990; Merckelbach, vivors without PTSD did not. This study demon- Muris, van den Hout, & de Jong, 1991; Wegner & strated for the first time differences in the perfor- Erber, 1992; Wegner, Schneider, Knutson, McMahon, mance of trauma survivors with and without 1991): (a) an immediate enhancement effect, de- PTSD when engaged in deliberate thought suppres- fined by increased occurrences of the thought when sion. Overall, the presence of a rebound effect in trying to suppress it, and (b) a rebound effect, de- the PTSD group and its absence in the no-PTSD fined by increased occurrences of the thought after group suggested that thought suppression might be suppression instructions are removed. relevant in the maintenance of intrusive symptom- Within the thought suppression literature, the atology. However, it was unclear if these effects paradigm’s applicability for understanding different were specific to recovery from sexual assault or types of psychopathology, including depression, were a psychopathological feature of PTSD irre- obsessive-compulsive disorder, and PTSD, has been spective of the type of trauma. Further, it was un- explored. Several reviews of this literature have sum- clear if the rebound effect was specific to trauma- marized findings to date (Beevers, Wenzlaff, Hayes, related information or if the effect was reflective of & Scott, 1999; Purdon, 1999; Purdon & Clark, general cognitive functioning. 2000; Rassin, Merckelbach, & Muris, 2000; One area yet to be explored with trauma survi- Wenzlaff & Wegner, 2000). These reviews have de- vors is the generalizability of the rebound effect to tailed some of the mixed findings, along with the thoughts
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