Introduction and Overview of Treatment

In the previous chapters, the various models, theories, and research about the consequences and etiology of PTSD have been covered. This chapter serves as an introduction to the various treatments derived from such work and the treatment of PTSD in general. Before we get into the specific models of treatment, from the variety of psychotherapies to biological treatments to integrated and comprehensive treatments, it might be helpful to take a broader and foun-dational view of treatment of PTSD...

Commonalities among Therapies

Wilson et al. (2001) identify the following characteristics that PTSD and trauma therapies and treatments have in common. On a broad scale, they all focus on reducing symptoms, improving functioning, improving relationships, promoting positive appraisal for the self and the world, listening, empathy, structure, well-timed and dosed intervention, caring and respect, ethical guidance, and the encouragement of self-empowerment and mastery. Specifically for PTSD, these same authors state that all...

Basic Principles of Behavior and Cognitive Behavioral Therapy

Behavior therapy involves the application of the principles of learning and behavior. Classical conditioning is used to explain the acquisition of abnormal behaviors through contingency learning in PTSD, this might account for the pairing of certain sounds (loud bangs or breaking glass) with arousal and escape or avoidance behavior. Operant conditioning, with its principles of positive reinforcement, negative reinforcement, and punishment accounts for behavior through an analysis of the...

Psychopharmacology 101

Psychopharmacological treatment of mental disorders is the direct outgrowth of the medical model within psychiatry, the biological revolution in psychiatry, and the biological and brain-based focus of psychology and the mental health fields. Psychiatry, for many years, was dominated by psychoanalytic formulations of mental disorders stemming to a large degree from Sigmund Freud and his followers. This is not to say that the biological and medical foundations of mental disorders were completely...

Core Symptom Assessment of PTSD

Once the presence of a traumatic event has been established and it appears that the patient's problems are contiguous with the event, the presence, intensity, and duration of the core symptoms of PTSD need to be evaluated. Is the patient demonstrating reexperiencing phenomena occurring in at least one of the following ways 1. The patient experiences recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note that in young children, repetitive...

Imaging Studies and Anatomical Changes

Lisa Shin, Scott Rauch, and Roger Pitman (2005) discuss three specific brain regions with structural and functional abnormalities related to PTSD pathology the amygdala, the medial prefrontal cortex, and the hippocampus. PET (positron emission tomography) scan and SPECT (single photon emission computed tomography) span studies analyzing regional cerebral blood flow of the amygdala have shown increased blood flow an index of activity-in the amygdala (Hendler et al., 2003 Liberzon et al., 1999...

Psychophysiological Assessment of PTSD

The prominent role of psychophysiological mechanisms in PTSD etiology and course are undeniable. Most psychophysiological assessment of PTSD has been relegated to research purposes. There are a few clinical applications, specifically for prediction of adjustment and treatment outcomes. Psychophysiological assessment typically involves measurement of one of four key physiological systems outlined by Orr, Metzger, Miller, and Kaloupek (2004) cardiovascular measurement, such as blood pressure and...

Evaluation And Assessment of PTSD

So far we have discussed the general issues of psychological evaluation and assessment that are important for any and all psychological and psychiatric problems. We now turn specifically to the evaluation and assessment of PTSD. Although the clinical evaluation of PTSD should be similar to the evaluation of other disorders, there are specific issues, approaches, and techniques especially relevant to PTSD. This is important to consider because a generic approach to the assessment of PTSD might...

Electrophysiological Findings in PTSD

A relatively newer paradigm for investigating neurobiological abnormalities in PTSD has emerged in the measurement of brain wave activity with a special kind of electroencephalogram (EEG) measure called event-related potentials (ERPs). Event-related potentials measure changes in EEG activity in response to stimuli and serve as indices of reactivity and habituation and learning against background resting-state activity. An ERP, for example, serves as a measure of the brain's reaction to novel...

Functional Assessment of PTSD

Memory, Attention, and Concentration Memory dysfunction is a common presenting problem from patients with PTSD and can be observed by third parties, such as family members, coworkers, or employers. Patients are told they are forgetting conversations they've had or tasks they were expected to perform. Memory problems can also be observed clinically in patients' inability to recall information from their pasts surrounding the traumatic event, missing appointment times, or forgetting to do...

Borderline Personality Disorder

Sometimes trauma, particularly repeated trauma, is considered to lead to long-term alterations in personality development, structure, and functioning. Some professionals postulate that personality disorders can develop. Some have proposed the concept of the posttraumatic personality to characterize these more pervasive and integrated forms of posttraumatic reactions. Allen (2001) cites that research has revealed a global relationship between trauma and personality disorders. He states that...

Critical Incident Stress Debriefing CISD

There is an almost intuitive understanding amongst people that telling or talking about what happened in a traumatic event has healing power and qualities. This may very well be part of our natural response systems to traumatic stress that allow for the majority of us to never develop PTSD. The formal process of being allowed to do this, to be able to review what happened and attempt to make sense of an event or events, has come to be known as psychological debriefing. Raphael and Wilson (2000)...

Professional Issues Ethics Risk Management and Self Care

There are at least two sides to every story. Much of this book is about the sufferers and survivors of PTSD. But sitting across from the traumatized are the professionals, clinicians, and therapists who hear their stories, bear witness to their pain, and attempt to assist them in their journeys back from fear and the persistence of painful memories. Whether a client or patient is suffering from the afflictions of a mental disorder, a subclinical syndrome, or a problem in living, a la Thomas...

Professional Self Care

Hudnall Stamm (1995) states in the preface of Secondary Traumatic Stress Self-Care Issues for Clinicians, Researchers, and Educators, trauma professionals are always at risk for being wounded by the work (p. ix). Professionals who work with the traumatized and PTSD sufferers are potentially at risk for developing a condition known as compassion fatigue or secondary traumatic stress disorder (STSD Figley, 1995 Miller, 1998). Secondary traumatic stress disorder is defined by Figley as the...

Consequences of Exposure to Traumatic Stressors

For the purposes of this chapter, the various responses or consequences of exposure to traumatic stress will be divided into two large categories (1) consequences identified by the American Psychiatric Association in the DSM-IV-TR, consisting of formalized diagnostic criteria and symptoms and (2) the biological, psychological, and social effects identified by researchers independent of the DSM-IV-TR. The pathological or abnormal responses to exposure to a traumatic stressor identified in the...

Complex PTSD and DESNOS

Treatment professionals and researchers have long recognized that reactions to trauma can include PTSD, but other sequelae of trauma can be just as problematic. These other complications represent perhaps a more severe or complicated form of PTSD that is now being recognized as Complex PTSD (CPTSD). Others sometimes refer to this form of complex posttraumatic reaction as disorders of extreme stress not otherwise specified (DESNOS). Judith Herman (1992) proposed the term Complex PTSD to capture...

Psychopharmacological Therapy for PTSD

There appears to be professional consensus that pharmacotherapy in PTSD is a critical and important treatment component for PTSD (Friedman et al., 2000a) for a number of reasons research supported biological abnormalities in PTSD overlap with other disorders that are very responsive to drug treatment, such as depression and Panic Disorder and its general acceptance by patients despite side effects and often prohibitive costs. The National Center for Post-Traumatic Stress Disorder proposes the...

Anger and Trauma

I don't believe it is overstating to say that anger is a relatively neglected concept in mental health research and practice. Consider the existence of literally hundreds of professional books on depression and only a handful on anger. Two classes of emotional disorders occupy a large portion of the DSM-IV-TR, depression (sadness) and anxiety (fear), but where are the anger disorders They're not in there I find the seeming lack of recognition of anger as a clinical issue odd, given that crimes...

Cognitive Behavioral Therapies for PTSD

The treatments covered in this section fall into one of the three (behavior, cognitive, or CBT) categories listed in the preceding section to one degree or another. However, most therapies are combined. In order to simplify things a bit, we will discuss the various treatments or therapies separately as behavior, cognitive, or CBT where appropriate and helpful. That is, if a therapy is primary behavioral, it will be discussed as a behavioral treatment, and so on. Table 12.1 might help with...

Cognitive Theories and Models

All cognitive theories of Posttraumatic Stress Disorder have the following features or components in common, according to Dalgleish (1999) Individuals have pretrauma beliefs and models of the world, self, and others that come into play when a trauma occurs. Traumatic stressors provide salient and typically incompatible information relative to these beliefs and models. Such information cannot be easily ignored nor integrated or assimilated into these existing belief structures and models. The...

Cognitive and Behavioral Treatments

The histories of psychology and mental health treatment specifically have seen periods in which certain phenomena are treated as central to an understanding of human mental life and behavior, while others are neglected, ignored, or written off as unimportant. Psychoanalysis once dominated until the behaviorists came along and warned us to stay out of the black box of the mind. Biological models have come to prominence within the last 10 to 15 years or so. The mid-twentieth century ushered in an...

David F Peck Psych

Pattern and growth in personality. New York Holt, Rinehart, and Winston. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC Author. Blanchard, E. B., Kolb, L. C., Pallmeyer, T. P., & Gerardi, R. J. (1982). A psychophysiological study of Post Traumatic Stress Disorder in Vietnam veterans. Psychiatric Quarterly, 54, 220-229. Blank, A. S., Jr. (1993). Vet centers A new paradigm in...

Safety Security and Attachment Psychodynamic Approaches to PTSD

Most students of psychology are familiar with psychodynamic theories of human psychological functioning, from the works of Sigmund Freud to W. Bion. Psychodynamic is the modern name for what most people would recognize as psychoanalytic. Psychodynamic theories are bound together by their rich history and tradition as well as by their core themes and conceptual focus. Psychodynamic theories of psychopathology have in common a focus on the internal struggle of the mind for the expression and...

Dissociative Disorders

Dissociation has long been considered an integral part of PTSD and posttraumatic reactions. After a traumatic event, survivors have often reported leaving their bodies or of observing themselves from the outside. One's sense of time can be distorted, and there can be a sense of unreality. Dissociation can be defined as a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. Bessel van der Kolk has proposed that at least in one...

Posttraumatic Stress Disorder and Neurochemical Processes

As was mentioned earlier, what lies at the root of brain alterations in PTSD are alterations in neurochemicals such as neurotransmitters, hormones, and neuro-peptides. These alterations ultimately lead to changes at the synaptic level, which lead to changes in circuitry and connectivity and the way different brain areas interact with and influence each other. These neural changes occur within the larger behavioral and neurobiological context of the stress response and the fear response and its...

References

M. (1996). Traumatization stress among Asians and Asian Americans. In A. J. Marsella, M. J. Friedman, E. T. Gerrity, & R. M. Scurfield (Eds.), Ethnocultural aspects of Posttraumatic Stress Disorder Issues, research, and clinical applications (pp. 285-299). Washington, DC American Psychological Association. Allen, I. M. (1996). PTSD among African Americans. In A. J. Marsella, M. J. Friedman, E. T. Gerrity, & R. M. Scurfield (Eds.), Ethnocultural aspects of...

General Treatment Goals and Principles

How can helping be defined with respect to PTSD From a phenomenological perspective, PTSD can be understood to be about fear, vigilance, and arousal. Consider the following sentiment by a patient in therapy for PTSD When I first started coming, I couldn't connect to anyone I was numb all the time. I didn't care if my son cried. I couldn't feel his pain. I don't know if it was the lack of sleep that kept me feeling like I was in a dream or a daze all the time. I'd go to work, and if I needed...

Ethnocultural Aspects of PTSD

At the outset of this book, I made the point that trauma is a near universal human experience. But as I have just finished saying, psychologists are increasingly questioning the concept of universality. Is trauma a universal experience Can all human beings be psychologically traumatized Some researchers argue that the very concept of psychological trauma is culturally constructed and, therefore, might be very different from one ethnocultural context to another. In fact, the very existence of...

What Are Stressors

Goldberger and Breznitz (1993) group stressors into two large groups, common stressors and extreme stressors. Common stressors are stimuli that are commonly experienced by many people. Traffic jams and job stress are good examples. Common stressors can emanate from a physical environment, such as living in an urban setting or being snowed in during winter or living in a metropolis with its noise and crowds. If you're not used to being crammed into a subway car with hundreds of people, it can be...

Other Biological Psychological and Social Responses and Consequences

Research has consistently shown that individuals diagnosed with PTSD have higher rates of medical services use and increased levels of fatigue, headaches, chest pains, gastrointestinal disorders, cardiovascular disorders, and impaired immunity functioning when compared to individuals not diagnosed with PTSD. There is also a tendency for such individuals to rate themselves as less physically healthy overall when asked. Keep in mind that the jury is still out as to the exact nature of the...

Stress Disorder

THE WILEY CONCISE GUIDES TO MENTAL HEALTH Introduction to Posttraumatic Stress Disorder Suffering breaks our world. Like a tree struck by lightening splintered, shaken, denuded our world is broken by suffering, and we will never be the same again. A timid person is frightened before a danger, a coward during the time, and a courageous person afterward. Happiness is nothing more than good health and a bad memory. Nothing fixes a thing so intensely in the memory as the wish to forget it. The...

Horowitzs Cognitive Analytic Approach

Mardi Horowitz (1988, 1997, 1998, 2001) is widely recognized as a top name in PTSD research, theory, and practice. Although his treatment modality is somewhat of a hybrid in that he incorporates a fair amount of cognitive concepts into his work, the core of his work is typically considered psychodynamic. Horowitz himself refers to his treatment approach as cognitive-dynamic. He approaches PTSD as a disorder within a larger group of syndromes called stress response syndromes. He characterizes...

Substance Abuse and Dependence

Researchers using something called an odds ratio, which measures the odds of having one disorder if an individual has the other disorder, have measured the rates of comorbid Substance Abuse and PTSD. Studies have revealed the range of odd ratios for comorbid Alcohol Dependence or Abuse is 2.06 to 4.25. This means that if someone has PTSD, his or her odds of having an Alcohol Abuse or Dependence Disorder is anywhere from two to four times higher than if they did not have PTSD. Regarding...

Summary

Perhaps the moral of the story for this chapter is that in order to gain a full appreciation of the individual suffering from PTSD, a serious application of the biopsychosocial model of human behavior and mental processes must be attempted. Posttraumatic Stress Disorder occurs within a mental and intrapsychic context and its complex dynamics. It occurs within a social and political matrix replete with roles, expectations, and identities. Finally, a respect for the complexity of PTSD and the...

The Self Psychological Approach

Self-psychology is considered a descendent of Freudian psychoanalysis and was developed by, among others, Heinz Kohut. Richard Ulman and Doris Brothers 1988 present a treatment approach from the Kohutian self-psychology perspective. At the core of self-psychology is the notion that the structure of the self is created through relationships. Each of us possesses the psychic structure, the self-object, to refer to someone who is important in satisfying our basic, narcissistic-oriented needs....

Constructivist Narrative Treatment

From Chapter 7, from the constructivist narrative perspective, traumatic events challenge or damage our personally constructed narrative representation of reality and the goal of treatment is thus constructing a new narrative and assumptive world that assimilates the traumatic experience is crucial to recovery. As Donald Meichenbaum 2000 states, People are story-tellers. . . . They offer accounts that are designed to make sense out of the world and their places in it. . . . Now, consider what...

Posttraumatic Stress Disorder and Specific Ethnocultural Groups

Before we begin to look at the various ethnocultural factors of some specific groups, a disclaimer needs to be made. Certainly, a discussion of all the various ethnocultural groups in the United States and elsewhere for that matter would by encyclopedic. The groups discussed in this section were chosen for a couple of reasons. Studies with these particular groups constitute the largest proportion of studies. Further, these three groups constitute the largest ethnic minority groups in the United...

Rape and Sexual Assault

Edna Foa and Barbara Olasov Rothbaum 1988 outline a comprehensive cognitive-behavioral treatment CBT approach to PTSD from rape and sexual assault. Earlier analyses of posttraumatic reactions to rape have been referred to as rape trauma syndrome Burgess amp Holmstrom, 1974 . Foa and Rothbaum outline these common affective and functional sequelae to rape in addition to PTSD core symptoms Anxiety intense fears of rape-related situations and generalized anxiety Depression may be more common than...

The Course of PTSD

After the traumatic stressor has abated, the hurricane is over, the battle has ceased, or the fire has been put out by heroic firefighters, what does a person in the midst of a developing PTSD episode experience Understanding the course of an illness is a vital aspect of medical science and clinical work. By course, we mean how a disorder behaves or looks over time. How do the symptoms emerge What pattern do they take Do some go away and then come back again And so on. The first phase of PTSD...

Integrated Theories and Models

Diathesis Stress Model Ptsd

Yule's, Williams, and Joseph's Integrated Psychosocial Model Yule, Williams, and Joseph present what they call a multifactorial model of PTSD that includes numerous components from other models and combines them into a complex of interrelated variables. Perhaps, the easiest way to approach an understanding of their model is to first present it as shown in Figure 7.1. FIGURE 7.1 An Integrated Psychosocial Model. FIGURE 7.1 An Integrated Psychosocial Model. To understand the model, begin with the...