Alternative Ways to Cure Posttraumatic Stress

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The Purpose of the CGPTSD

Few clinicians or mental health professionals can say they have never had a patient or client who presented with Posttraumatic Stress Disorder. Whether the trauma is war, car accident, or medical event, most mental health professionals will at some point be faced with the challenge of helping a traumatized person regain his or her sense of trust and safety. Professionals and lay people alike often find themselves needing more information on a particular disorder or case. Yet the seeming paradox of this information age is that there is sometimes too much information out there. Wait a minute, too much information How can there be such as thing as too much information Well, in an absolute sense there cannot be. However, the rate at which information is generated today is unprecedented. It's extremely difficult, if not impossible, to keep up. In true modern fashion, most us need and often look for a shortcut. There is so much information to be condensed and so little time. That is exactly...

Crisis Acute Stress Disorder and PTSD

Before we get into the details of the effects of exposure to traumatic stress, a quick word needs to be said about the difference between the immediate response to a traumatic stressor and more long-term responses. is defined as a temporary state of upset and disorganization, characterized by an inability to cope with a particular situation or stimulus using customary methods. The crisis literature is extensive, and for more information the reader is directed to Slaikeu (1990). However, PTSD is about the aftermath of such a crisis, both the relatively short-term effects (acute-more than 1 month but less than 3 months), long-term effects (3 months or more), or even the delayed effects (onset of symptoms 6 months after an event). Responses to traumatic stressors can be as varied as there are people in the world. A crisis may not necessarily lead to a mental disorder or psychiatric diagnosis. Some severe responses that would certainly constitute a crisis but not necessarily a diagnosable...

Exposure to Trauma and Risk for Posttraumatic Stress Disorder

Posttraumatic stress disorder is one of many reactions to danger. Traumatic events signal danger to life, limb, and even one's sanity. Just how dangerous is our world How risky is it to just wake up in the morning Accidents represent the fifth leading cause of death in the United States, ahead of diabetes, influenza, pneumonia, and Alzheimer's disease, according to the National Center for Health Statistics. What about violence Violence, including war, is one the most common sources of traumatic stress. There are many dangerous places in the world. The United States Department of State issues travel advisories for dangerous countries. The United States Department of Justice reports that in 2003 for every 1,000 persons aged 12 or older, there occurred one rape or sexual assault, one assault with injury, and two robberies. There occurred about 6 murder victims per 100,000 persons in 2002, and in 2003 there were 5.4 million crimes of violence. With all this danger, the risk for exposure...

Why Do Some Develop PTSD and Some Do

Figuring out why some people develop PTSD and some do not after exposure to a traumatic stressor requires an understanding of the risk factors. Is it personality Could it be genetic Why do some people seem to be traumatized over and over again Some seemingly trivial events have led to PTSD. When this is the case, personal vulnerability and risk factors become tantamount. A stressor alone is rarely enough to produce psychopathology. not as clear-cut as it might at first seem. Certainly, if someone possesses risk factors, he or she would be considered more likely to develop PTSD. But what if someone has 2, 3, or 10 risk factors Is he or she 2 times or 10 times more likely to develop PTSD The answer is we don't know. The risk factor issue is not a simple additive model, with the more risk factors you have adding up to PTSD. This may be the case, and it does make sense logically and even clinically. A clinician or professional working in prevention might want to operate on this...

Posttraumatic stress disorder

PTSD-related symptoms tend to be under-recognised in dermatology (Woodruff et al., 1997). The central clinical features of PTSD (American Psychiatric Association, 1994) include the persistent re-experience of extremely traumatic or stressful life experiences or life events, which can manifest as recurrent and intrusive thoughts, dreams, flashbacks or physical symptoms. There is a persistent avoidance of stimuli associated with the trauma and this can manifest as dissociative symptoms. PTSD secondary to childhood neglect and abuse, especially sexual abuse, is often the underlying psychiatric pathology in dermatological patients who self-induce their lesions. PTSD is often complicated by substance abuse disorders and this often becomes the main focus in treatment. When dissociative symptoms are a prominent feature of the PTSD, the patient may not have recollection of the fact that they self-induced their lesions (Shelley, 1981 Gupta et al., 2000) and may be misdiagnosed as malingerers...

Psychodynamic Psychosocial Alternative and Integrated Theories and Models of Posttraumatic Stress Disorder

Because of the wide range of approaches used to investigate the etiology of PTSD, PTSD perhaps represents the prototype for the use of the Biopsy-chosocial approach to understanding mental disorders. Although many other mental disorders have been approached from each of these three areas (e.g., depression or Schizophrenia), PTSD stands out as one of the most broadly investigated and multidisciplinary-involved disorders in the DSM-IV-TR. PTSD has been heavily investigated by physicians, psychologists, and even sociologists. As we have seen in Chapters 5 and 6, cognitive theories and biological models alike have given us powerful insights into the experience and etiology of PTSD on an individual basis. But like all psychological phenomena, these cognitive and biological processes occur within an interpersonal and social context that plays a powerful role in determining the development and presentation of the disorder. In this chapter, we will look at PTSD with the social and...

Traumatic Brain Injury and PTSD

Being hit with a pipe or baseball bat) and some with relatively mild difficulties (e.g., a mild concussion). However, the coexistence of PTSD and TBI is a controversial topic (Harvey, Kopelman, & Brewin, 2005) because oftentimes TBI patients have amnesia for a particular event, which would make the development of PTSD virtually impossible. How can someone reexperience something they don't remember, for example Earlier research showed a concordance rate of 0 percent for TBI and PTSD (Warden et al., 1997). However, more recent research has shown rates of comorbid PTSD and TBI to be anywhere from 14 percent to 27 percent. They can coexist. The TBI and PTSD picture is somewhat complicated. Traumatic brain injury patients, for example, may not experience the classic set of PTSD symptoms, and instead there may be differences in symptom experience and expression. An example of this is that intrusive memories may emerge much later in TBI patients than in non-TBI patients with PTSD. This is...

Treatmentof Post Traumatic Stress Disorder

Older antidepressants (imipramine, amitriptyline, and MAO inhibitors) are moderately effective, especially for symptoms of increased arousal, intrusive thoughts, and coexisting depression. Sertraline (Zoloft) has demonstrated efficacy for all the symptom clusters of PTSD. Other SSRIs are also likely to be effective. Treatment at higher doses than are used for depression may be required. B. Propranolol, lithium, anticonvulsants, and buspirone may be effective and should be considered if there is no response to antidepressants. Benzodiazepines have not been effective for PTSD, except during the early, acute phase of the illness.

Empirical Status of Psychodynamic Treatment for PTSD

According to the practice guidelines from the International Society of Traumatic Stress, only a few empirical investigations with randomized designs, controlled variables, and validated outcome measures have been reported (Kudler et al., 2000b, p. 339). However, numerous case studies have been published that establish the utility of psychodynamic treatment methods. It is suggested that before considering the use psychodynamic-oriented psychotherapy for PTSD, certain patient characteristics should be taken into consideration, including frustration tolerance, tolerance for strong emotions, psychological mindedness, intact reality testing, an ability to form and maintain relationships, impulse control, and an ability to sustain employment.

Psychopharmacological Prevention of PTSD

Part of effective treatment of PTSD involves prevention of full-blown PTSD from developing by intervening as immediately posttrauma as one can with debriefing, crisis intervention, and psychological first aid. This is particularly true in cases of Acute Stress Disorder. Interventions that can reduce immediate and acute posttrauma levels of arousal, such as relaxation training and utilizing social supports, are often effective. Can pharmacological treatment play a role in prevention or early intervention Stahl (2005) suggests that medications can be given to disrupt the psychobiological processes that lead to PTSD, ideally preventing the disorder but conservatively attenuating its severity. Two studies suggest that administration of propranolol may be effective as its effects on suppressing epinephrine may interfere with the formation of strong traumatic memories. Still other research is suggesting that early use of benzodiazepines and SSRIs, too, may be helpful. More research needs to...

Future Directions with PTSD

In reviewing the database PsycINFO just for the last 2 years, I found that well over 1,200 journal publications were found. In just 2005, well over 300 publications were found. These numbers represent a staggering amount of work being done on PTSD. If one was to predict the next big thing in the field, it might be reading and consuming the massive amounts of information being produced. Emerging trends and current research directions ascertained from PsycINFO for the year 2005 include the following Exploration of the relationship between PTSD and various health problems, including fibromyalgia, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), and severe acute respiratory syndrome (SARS) Terrorism and PTSD Neurofeedback treatment of PTSD Addressing the inclusiveness or exclusiveness of the PTSD diagnostic criteria Subsyndromal PTSD Complex PTSD Cross-cultural variability of PTSD Role of cognition in development of PTSD Psychosocial factors in the...

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 States. It is not my intention to communicate that other groups' experiences are not as important. For more information on various other groups and an in depth discussion of ethnocultural factors and PTSD, please see Ethnocultural Aspects of Posttraumatic Stress Disorder Issues, Research, and Clinical Applications (2001), edited by Anthony Marsella, Matthew Friedman, Ellen Ger-rity, and Raymond Scurfield. What is important to get from this section is that depending on historical factors,...

Ethnocultural Aspects of PTSD

Certainly in the United States, psychological trauma is understood primarily from a mental health perspective in the form of PTSD. Posttraumatic Stress Disorder symptoms have been identified in various other ethnocultural contexts, such as Southeast Asia and Central America. But is the American construct of PTSD the best way to conceptualize the psychological impact of traumatic stress for individuals of various other ethnocultural groups Remember again from Chapter 1 that acceptance of the PTSD construct into the official nomenclature of modern psychiatry and clinical psychology was dependent on the recognition that PTSD actually existed as a distinct clinical entity. In other words, the mental health community finally acknowledged the reality of psychological trauma. Posttraumatic Stress Disorder was formally recognized as a distinct set of reactions in response to exposure to a traumatic event or events. However, working from an ethnocultural perspective, the reality of PTSD once...

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 various brains structures and systems outlined in the preceding section. In the stress response, there is a release of stress hormones and activation of stress-related neurotransmitters systems. Figure 6.4 outlines the brain regions involved in this process. Research has shown that PTSD involves the activity of the following neuro-chemicals Catecholamine levels in the brain are responsive to stress. They are among the critical neurochemicals involved in stress and fear responding. When there are...

Safety Security and Attachment Psychodynamic Approaches to PTSD

The classical school begins with Sigmund Freud, who recognized that traumatic events could produce traumatic neuroses, conditions recognized by Freud to consist of intrusive imagery, physiological hyperactivity, active reliving the event as if it was recurring in the here and now (Wilson, 1995). A traumatic event threatens the ego with destruction or annihilation, and in order to cope with this threat, repression is employed as a defense. Freud characterizes traumatic stressors as overwhelming for the protective shield of the ego. There is a disruption in normal functioning and the ability to cope effectively with current stressors. Traumatic stressors and current stressors combine to overwhelm the ego and its defenses, thus leading to symptom expression. The strong affects related to the trauma press for expression in emotional or behavioral form. Edith Jacobson (1949) proposed that traumatic stressors represent an assault on our ego and result in a narcissistic disturbance inside...

Cognitive Behavioral Therapies for PTSD

Cognitive processing therapy Conceptually, from a behavior therapy perspective, PTSD is viewed as a specific form of conditioned emotional (fear) reaction. The natural emotional reaction is paired with particular stimuli and other related stimuli, which ultimately serve to maintain the conditioned behavior and responses over time. Successful behavior therapies for PTSD work to break the conditioning between the traumatic event and the conditioned emotional responses through subsequent learning episodes or trials. They also seek to increase behaviors that are incompatible with the high levels of arousal in PTSD, such as teaching breath control. Diaphragmatic breathing is sometimes taught as a means for patients to calm themselves down and maintain relaxation during exposure and desensitization procedures. Therapists train patients and encourage them to use this out of session as a means to manage their anxiety. Homework as practice is assigned, to be practiced several times a day....

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 use of pharmacological treatment for individuals who have already been through debriefing or brief crisis-oriented psychotherapy. Without being facetious, alcohol is probably the oldest form of medicinal treatment for PTSD. Heroin abuse and dependence was not uncommon in Vietnam and in those who returned home with addictions. In essence, any medicine, drug, or substance that could calm one's nerves might be sought out as a medicinal remedy to the distress of PTSD. Barbiturates, powerful central...

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 the panopoly of psychopathol-ogy frequently observed in the wake of extreme and repeated interpersonal trauma. Courtois (2004) defines it as a type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts. Complex PTSD can be conceptualized by seven problem areas associated with early interpersonal trauma (Courtois, 2004 Herman, 1992) Complex PTSD is considered an associated feature of PTSD-proper as identified in the...

Consequences of Exposure to Traumatic Stressors

The pathological or abnormal responses to exposure to a traumatic stressor identified in the DSM-IV-TR are grouped into three large categories symptoms of reexperiencing, symptoms of avoidance, and symptoms of arousal. Diagnostic Criteria for Posttraumatic Stress Disorder If one had to pick one symptom or sign that was the hallmark of PTSD, reexperiencing may very well be it. Hollywood and television portrayals of the disorder commonly depict the war veteran having a flashback, believing he is back in the combat zone, fighting for his life. When a trauma victim has a reexperience, he or she is in a state similar to the acute stress phase of the traumatic stress or stressor. Individuals may feel that they are in danger in the immediate moment. They may panic and want to escape. They may become aggressive or assaultive in order to protect themselves from the reexperience of threat. Intrusive thoughts, images, and perceptions are considered major features of PTSD. Kardiner (1941) states...

Functional Assessment of PTSD

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 between-session homework assignments, for example. The assessment of memory in PTSD in some ways is no different from assessment of memory in general. The Wechsler Memory Scale-Third Edition (WMS-III) is a widely used instrument with a solid research base across clinical populations and sound psychometric properties. The WMS-III has not been identified as a specific instrument for use in PTSD assessment, but its clinical utility will help any clinician assess a PTSD patient's memory functioning, whether dysfunction is viewed as related to...

Differential Diagnosis of Specific Phobia

Panic Disorder, Obsessive-Compulsive Disorder, Social Phobia, Hypochondriasis or Anorexia Nervosa. Many psychiatric disorders present with marked anxiety, and the diagnosis of specific phobia should be made only if the anxiety is unrelated to another disorder. For example, specific phobia should not be diagnosed in panic disorder if the patient has excessive anxiety about having a panic attack.

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 stimuli, with a reduction in activity as information is habituated to and is deemed repetitive or noninformative. Arciniegas and colleagues (2000) have proposed that the symptoms of hyper-vigilance and attention deficits in PTSD are consequences of a reduction in sensory gating. Boutros and Belger (1999) define sensory gating as follows Metzger, Gilbertson, and Orr (2005) propose that in PTSD, selective attention is impaired because of a failure to filter out irrelevant environmental stimuli. They...

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 leave many questions unanswered and ultimately lead to a client or patient not receiving the help he or she needs. John Wilson (2004) proposes a very useful and comprehensive approach to the evaluation and assessment of PTSD in order that these issues might be avoided. Wilson's (2004) comprehensive model of assessment includes two large areas of assessment, symptom clusters and adaptive behavioral considerations. There are five symptom clusters (1) reexperiencing, (2) avoidance, numbing, and...

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 heart rate measurement, with electrocardiograms (ECG) electrodermal measurement of skin conductance electromyographic measurement of muscle activity and electro-cortical measurement with electroencephalograms (EEG). Evidence of the various symptoms and components of PTSD has been provided. Reactivity to trauma-related cues, numbing of general responsiveness, sleep disturbance, irritability and anger, difficulty concentrating, hypervigilance, exaggerated startle responses, and persistent...

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. Norris and Hamblen (2004) also reviewed 17 instruments relevant to assessing the core symptoms of PTSD. Some strong instruments identified are the Posttraumatic Stress Diagnostic Scale, developed by Foa, Cashman, Jaycox, and Perry (1997) and the PTSD-Interview (PTSD-I), developed by Watson et al. (1991). The Posttraumatic Stress Diagnostic Scale inquires about DSM-IV symptoms occurring within the last month. Both validity (alpha .92) and reliability (r .83) are considered solid. The PTSD-I was developed for veterans, but Norris and Hamblen state it could be used for almost any population. The DSM-IV symptoms are identified as existing on a seven-point scale, ranging from no to extremely or never to always. Again, validity (alpha .92) and reliability (test-retest...

Differential Diagnosis of Post Traumatic Stress Disorder

PTSD may be an illness for which monetary compensation is given. The presence of a primary financial gain for which patients may fabricate or exaggerate symptoms should be considered during evaluation. E. Borderline Personality Disorder. Borderline personality disorder can be associated with anhedonia, poor concentration, past history of emotional trauma and dissociative states similar to flashbacks. Other features of BPD such as avoidance of abandonment, identity disturbance, and impulsivity will distinguish BPD from PTSD.

What Exactly Is a Traumatic Stressor

The truth is that even though we are all exposed to high levels of stress, including some of us who have been exposed to war, combat, and related stressors that would be defined as traumatic stressors, research has continued to show that most individuals exposed to stressors that would meet the definition of a traumatic stressor fail to develop PTSD, much like the citizens of Israel and Palestine. According to Breslau, Andreski, Federman, and Anthony (1998) only 9 percent of those exposed to traumatic stressors develop PTSD. It was once widely held that a direct linear relationship between the intensity of a stressor and symptom development existed. That is, if you were exposed to a traumatic stressor, you would develop PTSD. This is referred to as the dose-response model the more intense a stressor, the more likely PTSD will develop. Research has not supported this strict direct correlation (McNally, 2003). From this we can conclude that a traumatic stressor alone is necessary but...

Clinical Features of Specific Phobia

Specific phobias may result in a significant restriction of life activities or occupation. Vasovagal fainting is seen in 75 of patients with blood-injection injury phobias. B. Specific phobias often occur along with other anxiety disorders. C. Fear of animals and other objects is common in childhood, and specific phobia is not diagnosed unless the fear leads to significant impairment, such as unwillingness to go to school.

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 is referred to as the acute phase. This is different than Acute Stress Disorder as identified in the DSM-IV-TR. The acute phase of PTSD refers to the acuteness of the symptoms within a 3-month period posttrauma. If those symptoms continue longer than 3 months, the disorder is considered chronic. If the onset of symptoms occurs at least 6 months after the stressor, the disorder is considered delayed. Delayed onset PTSD is considered relatively uncommon. Blank (1993) identifies six patterns of...

Section One Theoretical and Empirical Foundations for

Working with Posttraumatic Stress Disorder Introduction to Posttraumatic Stress Disorder Exposure to Trauma and Risk for Posttraumatic Stress Disorder 55 Cognitive and Behavioral Theories and Models of Posttraumatic Stress Disorder Biological Theories and Models of Posttraumatic Stress Disorder Psychodynamic, Psychosocial, Alternative, and Integrated Theories and Models of Posttraumatic Stress Disorder

Frequently Asked Questions FAQs and Where to Look for the answers

What causes PTSD How do I know if I am suffering from PTSD Are some people more prone to developing PTSD than others I hope that the CGPTSD can live up to your expectations as well as my own. These were just a few points and tips to grease the intellectual gears and help ease you into your study of a tough and oftentimes disturbing topic. Just as many of us know the power of trauma, we also know the desire and pull to help those who suffer. If you haven't noticed so far, I tend to be light at times, and I like to use humor. This should not be mistaken for a carelessness toward PTSD or a minimization of the pain that PTSD can bring. I hope that my respect for survivors, their friends and family, and the countless others who reach out to help, shows in the thoroughness of this work and the quality of its presentation.

Conceptualizing Trauma

These points are particularly salient when it comes to the topic of trauma and posttraumatic reactions. Why Trauma invokes powerful images, thoughts, and feelings. It is a concrete and heavy concept because it is far too real for so many people. Because of this, each of us shows up to the trauma epistemology and ontology game with a lot of conceptual baggage. The philosophy of Edmund Husserl held that each of us possesses conceptual frames or brackets by which we organize and understand the world around us. He supported exploring these brackets in order to understand where our ideas about the world come from. This process was intended to address bias and misconception. I won't be asking you to discard your baggage or explore your frames necessarily, but simply to be aware. Self-awareness in the learning process is a powerful ally. As a therapist working with PTSD patients, I have seen my own conceptual baggage interfere with the listening and empathy process. As a writer, I am aware...

Individual Processes and Variables

The previous sections have addressed attempts at relatively comprehensive models of PTSD. In this section, individual research findings and theoretical work are discussed. Some of these may fit into one or more model discussed in In blaming ourselves, we engage in a process of finding the ways and means that lead to a particular situation, giving us a sense of control and a sense that had we engaged in other behaviors or made other choices, we could have prevented whatever it was that happened. This works for future events as well. We may say to ourselves such things as Next time I wont . . . or If this ever happens again, I'll be sure to . . . Keep in mind, however, that overusing the blaming-oneself method can put one at risk for depression and increase our focus on our perceived weaknesses rather than strengths. Intrusive and avoidant symptoms of PTSD have been theoretically connected to self-blame and shame. Shame may lead to avoidance coping, such as denial or social distancing....

Conceptual Foundations of the Biological Models

When trying to understand the biology of PTSD, it can be easy to get lost in the reductionism of the brain and its various systems and biochemical processes and lose sight of the big picture. The big picture represents the ultimate behavior of reacting or responding to danger, the protection of life and limb, and the training or learning occurring within the nervous system. In this chapter, we will be looking at the various brain processes, structures, and systems that underlie these processes. Before we get into the biological details of PTSD, something needs to be said about methodology and the issue of the level of study. The ideas and models discussed in this chapter will address numerous neurobiological processes including neuroanatomical structures and systems, neurotransmitter systems, neurophysiology, functional brain systems, neuropsychological functions, and endocrine and hormonal functioning. Each of these reflects a different level of analysis within the brain and body,...

Sources for Further Study

Jones, Loring, Margaret Hughes, and Ulrike Unterstaller. Post-traumatic Stress Disorder (PTSD) in Victims of Domestic Violence A Review of the Research. Trauma Violence and Abuse 2, no. 2 (2001) 99-119. An analysis of data from the literature focusing on the interplay between posttraumatic stress disorder (PTSD) and being a battered woman. The authors identified three major objectives of the study as well as seven major findings, chief of which is that PTSD symptoms are consistent with the symptoms of battered women.

Psychosocial and Alternative Models

In her book Trauma and Recovery, Judith Herman (1992) takes a very humanistic and sociopolitical approach to understanding posttraumatic stress and reactions. Her work is based in part on psychodynamic theory but also on a sophisticated and humane understanding of the role that traumatized people play in the social order, society, and our culture. She has combined both a clinical and social approach. Herman believes that trauma is an almost taboo subject and experience in most societies and that trauma victims suffer not only from the direct effects of the traumatic stressor themselves but also from a type of social trauma. She states, The ordinary response to atrocities is to banish them from consciousness (p. 1). That is, victims and those around them, including society as whole, wish to forget. For Herman, healing from trauma for both the individual victim and society requires that the events be acknowledged and their reality validated. We must bear witness if healing is to occur....

The Importance of Ethnicity and Culture

Professionals and researchers have come to accept that such concepts as depression, PTSD, or even the mind or psyche cannot be taken for granted across all ethnocultural contexts. Ironically, perhaps, the search for scientific objectivity has led us to the acknowledgment of ethnocultural variation and subjectivity as critical variables in our search. From a clinical perspective, this issue is extremely important. As stated in Gergen, Gulerce, Lock, and Misra (1996), the culturally engaged psychologist might help to appraise various problems of health, environment, industrial development, and the like in terms of the values, beliefs, and motives that are particular to the culture at hand (p. 1). In other words, efficacious and ethical psychological treatment and intervention will depend on the consideration of eth-nocultural variables. Perhaps the goal will be to build local knowledge bases rather than universal models of psychopathology and treatment. Perhaps conducting psychotherapy...

Plasticity Related To Traumatic Memory

Abnormal traumatic recall and fear responding (e.g. increased heart rate and blood pressure) can occur in PTSD patients in the absence of CS (e.g. intrusive memories, recurrent dreams, and flashbacks of the traumatic event). This suggests the potential existence of abnormalities in the circuits implicated in the emotional regulation of memory (e.g. the prefrontal cortex and the amygdala). Experimentally, traumatic memory is activated and expressed during exposure of PTSD patients to a provocative stimulus (e.g. traumatic pictures and sounds in combat veterans Prins et al., 1995), or when an aversive CS is presented to a previously conditioned individual (both animals and humans). In this latter case, animals (Gerwitz et al., 1997 Morrow et al., 1999 Quirk et al., 2000) or humans (Bechera et al., 1999) with lesions of the medial prefrontal cortex have been found to express normal traumatic memory. The only exception concerns lesions located in the more dorsal part of the medial...

Plasticity Related To Extinction

Although most of these studies have clearly shown that prefrontal lesions do not interfere with extinction of fear responding, analyses of neuronal activity within the medial prefrontal cortex have indicated the occurrence of specific plasticity related to extinction. In humans, two studies in which subjects were scanned before and after treatment for PTSD indicate such changes. In the first study, Levin et al. (1999) observed, in one PTSD patient, that treatment by eye movement desensitization and reprocessing is associated with increased activity in two areas the anterior cingulate gyrus and the left frontal lobe. Note that the patient was also on an antidepressant treatment (with a selective serotonergic reuptake inhibitor, SSRI) throughout the study. In the second study, Fernandez et al. (2001) found in one subject that pharmacological treatment (with a SSRI)-inducing extinction of behavioral activity in response to trauma reminders was associated with a conversion from depression...

General Evaluation and Assessment Issues

When I teach abnormal psychology, I often start out by asking my students to brainstorm various symptoms and signs of the particular disorder we are discussing for that lesson. This has gone a lot less smoothly than I initially thought. Students come up with a few key components, but not many or even most signs or symptoms. They typically are unable to paint me a picture of what a particular disorder actually looked like in the real world. Of course, I realize that my job as their professor is to teach them how to do this. A few guiding questions are usually helpful such as, What exactly does PTSD look like or How would someone with PTSD behave, think, or feel differently than someone without PTSD After we derive a fairly comprehensive list of indicators, I put a crucial and core question of psychology right back to them Before we go on, a key distinction needs to be made between psychological evaluation and psychological assessment. Psychological evaluation is a broader term and a...

Clinical Implications

Electrophysiological (Begic et al., 2001) and neuroimaging (Bremner et al., 1999 Pitman et al., 2001) data support the concept of an alteration of hippocampal functioning in relation to PTSD. Functional brain imaging data also argue for the involvement of the amygdala and the medial prefrontal cortex in the mechanisms underlying the expression of PTSD symptoms. Whereas neuronal activity increases in the amygdala during symptom provocation (Shin et al., 1997), the medial prefrontal cortex exhibits, on the contrary, decreased neuronal activity (Bremner et al., 1999). Although prefrontal data, both from animal and human studies, have yielded contradictory conclusions, more recent electrophysiological (Herry and Garcia, 2002) and neuroimaging (Fernandez et al., 2001) studies deserve, however, a little more consideration as potential tools for predicting treatment dropout. Indeed, following a complete elimination of PTSD-symptoms via an exposure therapy, follow-up data indicate that up to...

Getting Started Global Assessment

All clinical evaluations begin with identifying the presenting problem of a given patient or patients. Individuals with PTSD rarely come in and state, Hey, I have PTSD and here are my symptoms. Instead, much like most people presenting for mental health services, they complain of less core symptoms and of more peripheral problems. Here is a quick guide to common PTSD presenting problems Individuals with PTSD will often present with memory, attention, and concentration problems. They will report, or their family members will report, that they forget conversations, where they placed objects, and common daily events. They act spaced out. Agitation or irritability is also a common complaint. They report feeling keyed up or stressed out all the time. They might complain of feeling emotionally numb and disconnected from people. They might be having nightmares. No matter what the presenting problems are, once enough information has been ascertained by the clinician to suspect that the...

Background and History

When working with PTSD patients, the first order of business is to get a trauma history to determine whether a traumatic event has occurred. Simply ask the patient when his or her symptoms and problems began. Next, ask if he or she has been exposed to a traumatic event or stressor per the DSM-IV-TR criteria Have you ever experienced, witnessed, or been confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of you or others The phrasing of this question is an extremely important issue. If this question is asked too formally, patients might get confused. It always helps to ask the question in a language the patient can understand. Sometimes it is better to just ask, Have you ever almost died or Have you ever seen anyone get killed or die right in front of you These questions are fairly specific and, therefore, might not cover the range of qualified traumatic stressors, but they are often useful in stimulating the...

Issues in Treatment Planning

Treatment planning for any mental disorder or psychological issue or problem is an extremely important component to the healing process. In my own experience, this is perhaps the one professional skill or practice that separates the beginners from the novices and the novices from the experts. Having a well-thought-out plan is an invaluable tool. This is perhaps even more important when dealing with the all too typical complexity and chaos of PTSD. Before we get into some of the specific treatment planning issues for PTSD, let's take a quick look at treatment planning from a more general perspective. sider where you are in a physical sense. Can This material is intended prima- PTSD treatment be undertaken where you and rily for students and lay people, the client find yourselves For instance, if your but a little brush up never hurt job is to provide short-term-coping-based stabi-anyone' lization treatment to jail inmates, can you really engage in the complexity of PTSD treatment in...

Where Can One Get Treatment

Treatment for PTSD can be found broadly within the mental health service system that exists within one's community. Taking the limitations and restrictions on services that exist within any one setting, various degrees of treatment and types of treatment can be found in many different settings. The following is a list of places where one can seek treatment for PTSD

Who Performs the Treatment

Increasingly, PTSD is treated by a multitude of health and mental health disciplines, oftentimes within a treatment team and in a collaborative manner. The following is a list of professionals that one can seek help from Finally, if you are one listed in the preceding, you have to ask yourself whether you have the appropriate training, experience, or expertise to work with PTSD. (For resources on training, see Appendix A.) Consumers of mental health services, too, have the right to ask the person they are seeking help from about his or her experience, level of training, and level of expertise in working with PTSD.

HPA Axis Alterations in Other Psychiatric Disorders

When depression is comorbid with a variety of other disorders, such as multiple sclerosis, Alzheimer's disease, multi-infarct dementia, Hunting-ton's disease, and others, both CRF hypersecretion and HPA axis hyper-activity are common. In contrast, HPA axis dysfunction has rarely been reported in schizophrenia. Consistent with the role of CRF in both depression-like and anxiety-like behaviours in preclinical animal studies, increased CSF concentrations of CRF have been reported in post-traumatic stress disorder (PTSD) 95 . A recent elegant study that used an in-dwelling cannula in the lumbar space, allowing repeated sampling of CSF several hours after the initial, and presumably stressful, lumbar puncture, demonstrated elevated CSF levels of CRF in combat veterans suffering from PTSD 96 . In contrast, low serum cortisol and urinary free cortisol levels have been repeatedly, yet unexpectedly, detected in PTSD. One possible mechanism that has been proposed by Yehuda et al. 97 suggests...

The Dimensions Of The Problem

The effects of war, torture, and disaster on the mental health problem of refugees are manifested in several ways, including adjustment problems, depression, anxiety disorders or post-traumatic stress disorder (PTSD). The stressful condition of a refugee could even worsen any underlying mental disorders such as psychotic illnesses.

Studies Conducted in Areas Where Refugees Have Settled

Mollica et al. 4 , studying an Indo-Chinese group of patients in their clinic, found that 36 suffered from affective disorders, 1.9 from PTSD, 58 from affective disorders and PTSD, and 7.3 from other psychiatric disorders. Kinzie et al. 5 found that, out of 322 Indo-Chinese patients surveyed, 81 suffered from depression, 16 suffered from schizophrenia and 75 fulfilled a current diagnosis of PTSD. Lavik et al. 6 found PTSD in 48 , affective disorders in 16 , adjustment disorders in 10 and anxiety disorder in 6 of the group of refugees surveyed by them in an outpatient clinic in Oslo, Norway. These studies have been summarized in Table 8.1. Besides clinic-based studies, there have been many community-based studies of refugees. Sundquist 7 found that 18.3 of Latin-American refugees had some psychological distress compared with 2.8 of the control population of Swedes. Cheung 8 found 12.1 of the 223 Cambodian refugees surveyed by him to be suffering from PTSD. Sack et al. 9 conducted a...

Psychopharmacological Treatments

Psychopharmacological treatment of PTSD focuses on medications and their efficacy in alleviating symptoms and restoring stability to the biological systems and processes that underlie the disorder. Logically, psycho-pharmacological treatments are intrinsically tied to the brain systems and neurochemical processes that produce symptoms. Many authors have cited that psychopharmacological treatment of PTSD is relatively underdeveloped compared to other disorders and the casual observer might agree, particularly when compared to the medication treatment of Schizophrenia and depression. However, there has been considerable progress over the years for both specific symptoms and the syndrome as a whole. Throughout this chapter, the reader is encouraged to stay focused on three main areas of PTSD that are metatargets for pharmacological treatment deactivation, restoration, and stability. Medications are used to deactivate the hyperaroused and reactive brain systems, help facilitate...

Treatment of Comorbid Disorders and Associated Symptoms

More often than not, PTSD sufferers are plagued by comorbid or other association symptoms and conditions. Matthew Friedman states, people with PTSD exhibit abnormalities in almost every psychobiological system (p. 95). Kessler et al. (1995) estimate that more than 80 percent of individuals with PTSD have a comorbid psychiatric condition. Such disorders and related conditions as depression, Generalized Anxiety Disorder, Panic Disorder, psychosis, substance abuse, and irritability and anger should be addressed with their respective and indicated medications, with proper attention paid to interaction effects and how the treatment of these issues ties into the overall clinical picture. Selective serotonin reuptake inhibitors are implicated for treatment of depression and Anxiety Disorders as well. Effective medications for psychotic symptoms include Zyprexa and Seroquel. Methadone has been effectively used in the treatment of Opioid Dependence. Fluoxetine has been used successfully in the...

Integrated and Other Treatment Approaches

The developmental history of mental health treatments parallels the development of any scientific endeavor, including the development of the various health and clinical sciences. The objects of study change with paradigm shifts, technological advances, and social forces that any particular practice exists among and within. The treatments discussed in the previous chapters (Chapters 12, 13, and 14) in some respects represent the more stereotypical forms of treatment for mental disorders in general and PTSD specifically. The treatments to be covered here are less mainstream in some ways and less rooted in the historical tradition of mental health treatment. However, this is not to imply they are lacking in efficacy, sophistication, or rigor for these reasons. Just as the history of psychology, for instance, moves from paradigm to paradigm, from psychoanalysis to behaviorism to cognitivism, so, too, do these shifts occur in the development of clinical science and practice.

Integrated Approaches

Eye movement desensitization and reprocessing emerged as a trauma treatment from the astute observations of Dr. Francine Shapiro in the late 1980s. It has been used since and has enjoyed empirical support as an effective treatment for PTSD. It is considered an integrated treatment because it combines cognitive, behavioral, neurophysiological, and information-processing elements. Eye movement desensitization and reprocessing has gone from being a heavily doubted and suspiciously acknowledged therapy to being more widely used in the years since its introduction and being used with a wide range of clinical populations. Some consider it a significant breakthrough and substantial advancement in the treatment of PTSD (Parnell, 1997). and Nicosia (1994) propose that EMDR creates alterations in brainwave activity between cerebral hemispheres that allow for consolidation and interhemispheric communication. (For more on the biology of PTSD, see Chapter 6.) In 1995, Shapiro proposed an overall...

Disaster Research As An Application Of Psychiatric Epidemiology

The earliest disaster studies were case studies of specific events. Parallel with developments in research methods in epidemiology generally, particularly case-control methodologies, disaster researchers began to apply the basic principles of epidemiology to understanding the psychological aftermath of these events. For example, the case-control design was recently applied by Asukai 29 in a study of PTSD among firefighters who had been called in as rescue workers after the Sarin nerve gas attack in the Tokyo subway. They found that PTSD occurred more frequently in firefighters hospitalized with signs of Sarin poisoning, while most non-PTSD subjects had no, or only mild, intoxication. There have been some notable exceptions, however, in which a population happened to have been studied prior to the disaster, and then a postdisaster follow-up was performed. One example involved a population in Puerto Rico who had participated in a psychiatric epidemiologic study modeled on the...

Motor Vehicle Accidents

For those people who have ever been involved in a motor vehicle accident, you know what I mean when I say the sounds of twisting metal, shattering glass, and screeching tires and brakes are like no others. Together they form a perceptual conglomerate that can be firmly stamped into our memories and difficult to get out. They represent a soundtrack of trauma for those persons traumatized from being in an automobile accident, the way explosions, screams, and gunshots may represent the soundtrack for combat trauma. Even as I write this, I have images, though not intrusive, per se, of my own car accidents shamefully, there have been a few too many. Posttraumatic Stress Disorder can develop in a certain percentage of car Miller (1998, p. 122) cites that some estimates are as high as one-third of car drivers who have been involved in an accident with a fatality suffer persistent psychological aftereffects, including PTSD. One study showed that nearly 50 percent of car accident victims who...

Medical Traumatic Stress

Trauma researchers and practitioners, within the last few years, are more widely acknowledging the concept of medical traumatic stress, defined as the development of PTSD symptoms in relation to life-threatening illness, injury, or medical procedures, treatment, or intervention. Most of the work has been done with children, with focus on very serious medical procedures and illnesses, such as organ transplants and cancer. This is in part because of their life-threatening potential. The remainder of this section will focus on pediatric or child medical traumatic stress (M-PTSD). Some risk factors for developing M-PTSD include perception of threat to life and the intensity of a particular treatment or intervention. The more invasive and dangerous a procedure is, the more potential there is for M-PTSD. Burn injury has been associated with an increased risk of M-PTSD (Stoddard, Norman, Murphy, & Beardslee, 1989), in part because of the often horrendous pain involved. Laurence Miller...

Disaster And Postdisaster Risk Factors

The severity of the exposure is by far the most important disaster risk factor for the development of post-disaster psychiatric morbidity 42, 75 (Table 10.1). One of the most poignant descriptions of survivors' coping with mass destruction comes from descriptions of the survivors of Hiroshima in which an American psychiatrist, Robert J. Lifton 24 , recounted the survivors' horror and loss of feeling from witnessing mass death and dying and being unable to respond to calls for help, a phenomenon later referred to as psychic numbing. Indeed, this early description was the forerunner of the current nosology of PTSD. Severity can be measured by the magnitude of

Future Research Directions and the Cutting Edge

At the end of virtually every research article in psychology and psychiatry is a section named, Issues in Need of Further Investigation or Future Directions. It is intended to outline what the study or article failed to do to the author's satisfaction and leaves room for what particulars need to be addressed further. One of the main features of science is that it progresses, with scientists building on and adding to the findings of those who came before them. Although it appears to take steps backward, science keeps moving forward. The fields of traumatology and PTSD theory and research are no exception to this ever-moving force within science. The history of PTSD reflects an evermore sophisticated, complex, and widening breadth of understanding of the etiology, assessment, and treatment of traumatic stress disorders and syndromes. The majority of this book has been about the current state of affairs in the field of PTSD studies. Let's take a look at where we've been heading and what...

Understanding and Mining the Trends

In setting out to develop this chapter, I had to engage in a little bit of a crystal ball exercise of sorts. Well, that might sound a little too unscientific or systematic. How exactly can the trends and future of PTSD studies be spotted I will confess that I make no claim to being a visionary. In fact, my method for trying to figure out where the field is going was quite simple and tedious. It was also systematic, however. PILOTS database from the National Center for Post-traumatic Stress Disorder National Center for PTSD Research Quarterly from the National Center for Post-Traumatic Stress Disorder National Center for PTSD Clinical Quarterly from the National Center for Post-Traumatic Stress Disorder

Important General Societal Trends

A final trend worth mentioning is an informal but definite movement across the various sciences that can be referred to as a movement toward unification in science. The trend in many disciplines is to cross disciplinary lines and work from any number of approaches to address common problems. The field of PTSD research and practice, in fact, represents this trend quite well. Work on PTSD includes players from medicine, neuroscience, psychobiology, biology, psychology, social work, and even political science. This is an exciting trend in many ways as one might imagine that the academic institution of 10 to 20 years from now might have very different majors than it does now (e.g., neurophilosophy, computer psychology, or cyborg robotics). Before we go into some specific trends with PTSD, the following quick list of hot and emergent topics in mental health, psychiatry, and psychology might be of interest

Specific Technological Innovations

Three innovations and trends in PTSD treatment deserve specific attention Internet-based assessment and treatment, virtual-reality therapy, and transcranial magnetic stimulation. Each of these is making use of exciting new technologies Internet-Based Assessment and Treatment of PTSD European researchers Lange, Rietdijk, Hudcovicova, van de Ven, Schrieken, and Emmelkamp (2003) developed and tested an Internet-based treatment for PTSD. Internet-based therapy, although new and with many ethical and practical issues yet to be worked out, is a promising line of inquiry and practice. In contrast to simple computer-based therapy or even workbook-based therapy, Internet-based therapy provides direct feedback to the patient or participant via computer and the Internet. Internet-based therapy is promising for many reasons. Patients who live in remote areas, those with mobility or transportation problems, and those who have difficulty leaving their home because of psychological or symptomatic...

Caring For Expatriates In International Settings

Although 'self-care' is necessary, it appears that most do seek help from health care professionals for more complex medical problems. Professional help should also be sought in cases of psychosis, severe depression, suicidal ideation, anorexia nervosa, PTSD, serious difficulties with a child (including the possibility of abuse), or any mental health problem that appears to be getting worse. Organizations could increase the potential for more effective care by fostering a culture that promotes help-seeking behaviour (MMWR, 1999). After any traumatic incident, it is wise to ensure that there is adequate time to rest. Accidents are more common following a stressful experience, and so the individual should be encouraged to take particular care, especially when driving. PTSD can develop months or even years after a traumatic event, perhaps being triggered by a subsequent event, and so follow-up support should be offered should the expatriate wish to receive it at any point.

Debriefing A Reflective Pause

Approximately 25 of returned aid workers report clinically significant symptoms of avoidance and intrusive thoughts months after returning from a post overseas (Lovell, 1997). Although they do not necessarily meet the diagnostic criteria for PTSD, such symptoms are distressing and can interfere with normal functioning. One study indicated that after a single session of personal debriefing, lasting on average about 2 h, only 7 of aid workers reported clinically significant levels of avoidance or intrusion (Lovell, 1999b). This suggests that personal debriefing may play an important role in preventing the development of PTSD-related symptoms.

Ethical Considerations and Risk Management

Ethical practice begins with knowledge of ethics guidelines and principles. A clinician must also know who his or her client is and the parameters under which they work, whether it is in private practice, an institution, a government agency, and so on. Sometimes ethics and law collide or contradict each other. Ethical and safe practice must also include a working knowledge of the specific risks for working with specific clinical issues and populations. For example, I learned early on in my training that if you are going to work with children, you are going to face a child abuse-reporting situation eventually and sometimes often. Various populations bring their own risks. Working with Personality Disorders may involve constantly managing suicidal or self-destructive crises. When working with PTSD patients, risks may include strong countertransference reactions, burnout risk, emotional contagion, being involved in litigation and legal proceedings, addressing repressed memories, and...

The Migration Process And Health

This may differ greatly according to the legal status of a particular person or community. The level of education, professional skills, language and communication skills will influence the capacity of migrants to adjust to the new cultural, professional and social environment and progressively interact with and integrate into the new society. Previous exposure to violence and trauma may pose a serious barrier to adaptation, as persons suffering from post-traumatic stress disorder (PTSD) may avoid contacts or over-react to new unexpected constraints or situations. Living conditions, such as overcrowding or isolation, may accelerate the transmission of diseases such as tuberculosis and varicella, or may have an important psychological impact. Restrictive policies aimed at discouraging newcomers from seeking asylum may have also a deleterious effect on the mental health of asylum seekers or migrants (Silove et al., 2000). Access to health services may be...

Mental Health and Violence

Recently, the mental health of refugees and other migrants affected by conflicts has attracted more attention and become a priority for WHO (Brundtland, 2000). Studies conducted in the field have shown a high prevalence of traumatic events with high levels of mental morbidity (50 ) and PTSD symptoms (De Jong et al, 2000 Lopes Cardozo et al., 2000). In refugees and asylum seekers arriving in European countries, similar rates have been observed. Over 60 of asylum seekers arriving in Geneva, Switzerland reported having been exposed to trauma, 18 to torture and 37 reported at least one severe symptom during the previous week, most often of a psychological nature, such as sadness most of the time, insomnia, nightmares and anxiety (Loutan et al., 1999). Exposure to war-related trauma or torture may jeopardise seriously their capability to adjust to a new environment and a new society. Adaptation difficulties can be numerous and the administrative status may or may not facilitate this...

Integrated Theories and Models

Diathesis Stress Model Ptsd

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. Event stimuli. A traumatic stressor. Event cognitions. Mental representations that are either not available for conscious inspection or information is intentionally retrievable. These are the basis for reexperiencing symptoms of PTSD. In essence, what Yule's, Williams and Joseph's model is saying is that an event triggers a cognitive response that is determined by a person's personality and appraisal outcomes. Appraisal outcomes are determined by personality, emotion, and coping in a cyclical feedback loop. The environment and social context are both independent but are influenced by the person's coping responses. The model, although complex, takes a sophisticated approach in its...

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 & Holmstrom, 1974). Foa and Rothbaum outline these common affective and functional sequelae to rape in addition to PTSD core symptoms The PE alone schedule is recommended as a first-line approach, particularly for uncomplicated PTSD as opposed to complex PTSD. The PE plus cognitive restructuring schedule is suggested for patients who have both anxiety and a significant amount of guilt, shame, and debilitating anger. Dealing with negative automatic thoughts, dysfunctional beliefs, and cognitive distortions is an integral part of this approach, and Foa and Rothbaum (1998) suggest the use of a client-self-report daily diary as a means to record cognitive components. This provides a ready list of specific cognitions that are...

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 happens to people's stories when really bad things (traumatic events) are experienced (p. 55). Characteristics of individuals with ongoing PTSD symptomology include an inability to integrate their trauma stories, continued searching for an explanation and failures to find satisfactory answers to the why questions, constant engagement in counterfactual and what if thinking, and continual comparisons between life as it is and life as is could have been. Meichenbaum characterizes this narrative...

The Self Psychological Approach

Ulman and Brothers (1988) point out several important issues for the initial phase of treatment. They warn that it is important not to push too hard for the establishment of a self-object transference too soon as this may further fragment and disorganize the patient. Further, the clinician wants to be careful not to create a false transference based on a fantasy bond between patient and therapist. Resistance to the establishing of a transference fantasy of self in relation to a positive mirroring and idealizing object may occur as well. This resistance needs to be analyzed. Kohut cites two types of resistance that the therapist might encounter nonspecific narcissistic resistance, in which the patient resists loss of independence and autonomy by the act of coming to someone else for help, and specific narcissistic resistance, which is related to the patient's disturbed self and unconscious fear of disintegration. A focus on symptoms and the more technical aspects of PTSD help focus the...

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 Substance Abuse or Dependence, the range of odds ratios from various studies is 2.48 to 8.68. Again, this means that the odds of someone with PTSD also having a comorbid Substance Abuse or Dependence Disorder is anywhere from 2.5 times to 8.5 times higher than if he or she did not have PTSD. Posttraumatic Stress Disorder patients with comorbid Substance Abuse or Dependence Disorders have been found to have higher levels of pathology in both disorders, more stressors, higher rates of health care...

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 the pathology of stress response syndromes in the following way Traumatized individuals will predictably go through a series of alternating phases between acknowledging the trauma and avoiding it. As this process goes on, the eventual goal should be a reformulation or reschematization of the event in relation to the person and the person in relation to him- or herself and others. This is sometimes referred to as working through, which was mentioned earlier. The goal of treatment is to help the...

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 relationship between PTSD and physical health problems and disease. Some researchers propose the existence of mediating variables such as drug or alcohol abuse to be responsible for the observed relationships thus far. It is not clear from the research so far whether physical health problems associated with PTSD are the result of somatization physical health problems resulting from the actual physical aspects of the event (e.g., smoke inhalation from a fire, starvation as a prisoner of war, or exposure...

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 Treatment for PTSD is about restoring one's sense of mastery, safety, and security in the world, from helping the brain break loose from fear conditioning to helping the mind break loose from its vigilant search for threat and to gain self-control. The following are some principles that should guide PTSD treatment Shalev, Friedman, Foa, and Keane (2000) provide the following suggestions for developing treatment goals in PTSD treatment, selecting a treatment, and addressing various complications that may arise 4. Does the patient first need to realize that he or she needs to address his or her PTSD and seek help 1. Expected efficacy against PTSD. (Does the treatment work for PTSD ) 3. Addressing complex clinical pictures andcomorbidconditions. Ideally, practitioners should...

Clinical Forms of Anxiety

Among the forms of pathological anxiety, the DSM-IV-TR 1 distinguishes, in addition to generalized anxiety, phobias, panic attacks, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). There are some theories that since OCD involves structural and functional organic deficits, it is questionable whether it can be classified as an anxiety or depressive disorder 2 . The ICD-10 3 in fact classifies this disorder separately from the other manifestations often associated with it.

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 sense, dissociation may be functional by allowing a trauma victim to observe the experience from a safe, less intense distance, protecting his or her awareness from the trauma. In this sense it may serve as a form of psychological shock, a form of protective detachment. Dissociative failure to integrate traumatic memories, perceptions, cognitions, and bodily memories during the acute stage and the immediate posttrauma period is a risk factor for developing PTSD. Prior episodes of dissociation...

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 era in which the mind reemerged. This approach to mental life was a break from psychoanalysis and owed a great deal to developments in the field of cognitive science. This era is sometimes referred to as the cognitive revolution. The mind once again mattered, and there were fresh ways to approach it without reference to legions of Freud. The cognitive approach took root in both experimental psychology and eventually in the treatment of mental disorders and psychotherapy. With respect to...

Cognitive Theories and Models

All cognitive theories of Posttraumatic Stress Disorder have the following features or components in common, according to Dalgleish (1999) Traumatic stressors provide salient and typically incompatible information relative to these beliefs and models. The process of attempting to integrate this difficult and problematic information leads to what is observed as the PTSD phenomena (i.e., symptoms and signs of the disorder). hypothetical mental constructs, derived from experimental cognitive psychology, that address how individuals perceive, selectively attend to, and retrieve personally relevant information from memory. Information processing . . . addresses how life experiences are organized in memory in a manner that facilitates the utilization of past experience. Past experience is organized in memory in functional units called networks or schemas . . . Information processing theories of PTSD posit that traumatic life experiences influence how new information relevant to the trauma...

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 Secondary traumatic stress disorder and PTSD are virtually the same, with the difference being between direct exposure versus vicarious exposure. Figley (1995) considers compassion fatigue, compassion stress, and secondary traumatic stress disorder as synonymous. It is also sometimes referred to as burnout, emotional contagion, secondary victimization, covictimization, or secondary survivor syndrome. Figley (1995) has even developed an instrument to measure compassion fatigue in professionals called...

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 Szasz (1974), the mental health professional working with them is being asked by the patient, society, their profession, and by him- or herself a basic question, can you help this person I remember when I told some friends of mine that I was going to become a psychologist and go to graduate school. Although I am embarrassed to admit this, some of them reacted with a question of their own, who are you to think you can help people This question was not so much about whether I thought I had all the...

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) state that debriefing is an attempt to facilitate this type of review. Prevent the development of later psychological sequelae (e.g., PTSD). Although the steps outlined in the preceding appear to be straightforward and perhaps rather simple, CISD is a technical intervention, and it is recommended that those who wish to provide it be specifically trained and even certified in CISD provision. Also, as is the case with psychological first aid, ultimately, CISD and other forms of psychological...

Borderline Personality Disorder

Gabbard (2000) cites that childhood maltreatment is considered an etiological factor in BPD. The symptoms of BPD include fears of abandonment, unstable and intense relationships, disturbance in identity, self-destructive behavior, recurrent suicidal and self-injurious behavior, unstable affect, feelings of emptiness, intense anger, transient psychosis, and dissociation (Allen, 2001). The causal or precise etiological relationship between trauma and BPD has not been fully delineated yet, but promising lines of research indicate that the same biological underpinnings of PTSD may be active in BPD. Marsha Linehan and colleagues' diathesis-stress model is considered a good model although it requires more empirical investigation.

Differential Diagnosis of Social Phobia

Obsessive-Compulsive Disorder, Specific Phobia, Hypochondriasis, or Anorexia Nervosa. Anxiety symptoms are common to many psychiatric disorders such as depression and the anxiety disorders. The diagnosis of social phobia should be made only if the anxiety is unrelated to another disorder. For example, social phobia should not be diagnosed in panic disorder if the patient has social restriction and excessive anxiety about having an attack.

Disorders in Child and Adolescent Population

Children form one of the most vulnerable groups among refugees. Often they are the neglected lot. Psychiatric problems among refugee children are more prevalent than among the normal population of the same age. Although it has been argued that children are able to cope much better than adults, the fact remains that a large number of children among the refugee population suffer from mental disorders. Studies reveal that children, like adults, suffer an increasing number of psychiatric problems, among which PTSD, depression, anxiety and conduct disorders are the commonest ones. In Finland, Sourander 51 found that 48 of the surveyed refugee children had symptoms of PTSD, depression or anxiety. Fox et al. 52 found depression in 51 of the South East Asian refugee children surveyed by him in the USA. Sack et al. 53 conducted a long-term study using standardized instruments to assess the prevalence of PTSD and depression in a group of Cambodian children. They found that over a 12-year period...

Other Forms of Stress Exposure

Studies on African-American cultural factors pertaining to stress, emotion, or pregnancy. Parker Dominguez and colleagues (2005) found that neither anxiety nor perceived stress was significantly correlated with gestational age or low birthweight among 179 pregnant African-American women. Instead, a newer measure of the extent to which women experienced intrusive thoughts or rumination about their two most severe major life events was associated with lower birth weight when gestational age in linear multiple regression analyses was controlled for. Intrusive thought is a recognized symptom of trauma containing both cognitive and emotional components (and is often symptomatic of posttraumatic stress disorder). The possibility that low-income African-American women experience more symptoms of trauma and that these are more important risk factors for preterm birth than depression or anxiety for this or other groups is intriguing. More generally, researchers must address the possibility...

Psychopharmacology 101

Marked mood lability exists, especially in response to environmental events, with rage or depression. I would add irritability and even significant fear-reactions as is seen with PTSD to this factor. The classes of drugs used in psychopharmacological treatment are defined dually by the disorder and symptoms they are used for and targeting the underlying neurobiological effects and mechanisms. Table 14.1 summarizes the major classes of drugs used primarily in the treatment of depression and Anxiety Disorders including PTSD, with some examples and their underlying target neuro-chemical processes.

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 conditions or consequences that follow it. In PTSD, negative reinforcement might account for maintaining the core symptoms of avoidance, for example. Extinction occurs when a behavior ceases to be reinforced and may be helpful in eliminating particular behaviors by the withholding or preventing of reinforcement. The principles of discrimination, stimulus control, and generalization are important in understanding how particular stimuli elicit particular responses and how these same responses may be...

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, Specifically for PTSD, these same authors state that all the various therapies have at least two other things in common, their engagement in or operation along three metaphases of treatment and the extent to which they vary along a continuum of suppression or expression of the trauma. Here are the metaphases

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 as a whole. The costs of not helping victims of trauma are far reaching, on both a societal and individual scale. Entire groups and communities can develop entrenched and long-standing deficits that result in large-scale dysfunctions and ill health. For example, the American people have lived with the consequences of the Vietnam War veterans returning home with PTSD for almost 40 years. The effects of trauma, unacknowledged and untreated, can be seen in generation after generation following mass...

Principal Publications

Two-year fellowship at the Austin Riggs Center, a small private psychiatric hospital in Stockbridge, Massachusetts, which had been founded in 1919. The Center provided Beck with extensive experience in treating patients who needed long-term psychotherapy. When the Korean War broke out in 1951, Beck moved to Pennsylvania and accepted the position of assistant chief of neuropsychiatry at the Valley Forge Army Hospital. There he treated soldiers suffering from what is now termed post-traumatic stress disorder, or PTSD. Beck received his board certification in psychiatry in 1953, joined the Department of Psychiatry of the University of Pennsylvania in 1954, and completed his graduate training in psychoanalysis at the Philadelphia Psychoanalytic Institute (which changed its name to the Psychoanalytic Center of Philadelphia in 2001) in 1958. Beck remained at Penn until he retired from active teaching in 1992, when he was appointed University Professor Emeritus of Psychiatry. In addition to...

How to Bring the Unrepressed Unconscious to the Surface in Analysis

Verbal and presymbolic events of the implicit model of the patient's mind. The dream offers internal figures-or objects-that are related among themselves (its intrapsychic dimension) and to outside objects (its intersubjective dimension). The dream can create images or make a mental figurability, closing the gap created by the absence of representation, and symbolically configuring experiences that were originally presymbolic. Their interpretation will facilitate the process of reconstruction necessary for the mind to become able to mentalize and render thinkable-though obviously still not recollectable-experiences that originally could not be represented or even thought. The dream therefore works in the memory, drawing on repressed experiences stored in the explicit memory, activating their recollection, but also recuperating possibly traumatic events from the implicit memory, where they cannot be remembered. In this case the dream helps reconstruct a person's earliest history,...

Predisaster Risk Factors

In the absence of baseline data in most studies, the literature on pre-disaster risk factors is rather limited. To date, the most reliable predictors of postdisaster psychopathology are female sex and especially being a mother of young children 16 . After the TMI disaster, women with young children showed significantly increased rates of anxiety and depressive disorders compared with non-exposed controls, as assessed with the Schedule for Affective Disorders and Schizophrenia-Lifetime (SADS-L) (risk ratio 3.4 for new cases 99 ). In a within-sample analysis of risk factors among a large population sample in Belarus exposed to the Chernobyl disaster, Havenaar et al. 16 found that being a mother was associated with a 4-5-fold risk of having a DSM-III-R anxiety disorder and an almost 3-fold risk of any psychiatric disorder. However, these variables are also risk factors for poor mental health in non-disaster studies 100-102 . Nevertheless, the consistency of the findings in disaster...

Psychodynamic Treatments

There are numerous schools of psychodynamic therapy, and it would be impossible to touch on the nuances of each in this space. However, each of them has the elements in common mentioned earlier. Psychodynamic therapies for PTSD are also diverse, but they all have a psychodynamic formulation of patient symptoms and functioning as their base or core. In psychodynamic theory and therapy, a posttraumatic symptom is an adaptive attempt to manage the trauma (Kudler et al. 2000a, b). (For more on the psychodynamic theory of PTSD, see Chapter 7.) Trauma overwhelms us, and in response we engage in psychic defensive action and eventually will return to a state of balance between psychological resources and environmental demands (a situation that traumatic stressors obviously strain). Kudler et al. (2000a) state In PTSD, mental equilibrium has not been reestablished because the adaptive Specific psychodynamic psychotherapies have been developed, including the work ofJohn Briere, Mardi Horowitz,...

Other Psychodynamic Approaches and Techniques

Judith Chertoff (1998) proposes treatment of PTSD from an ego psychology perspective. She defines the ego as a complex dynamic system of internal, and often unconscious, defenses and function that mediate between the physiological and emotional needs of the self, such as food, nurturing, or erotic gratification, and the demands of the external world (p. 37). Practitioners from the ego psychology perspective work from a foundation in Freud's structural model (ego, id, and superego) and view trauma as an external event that overwhelms the ego's defenses and results in regression. Marshall, Yehuda, and Bone (2000) suggest that psychodynamic treatment of PTSD should focus on facilitating the resumption of the patient's stalled attempt at processing the event. They state that psychodynamic therapy helps, 1. Trauma reconstructions should occur when intrusive rather than numbing aspects of PTSD are present.

Current Status Of Disaster Research

Nevertheless, attempts have been made to assign a range in rates of psychopathology (e.g., PTSD depression somatization) to post-disaster survivors. Weisaeth 49 estimated that the 1-year post-disaster prevalence of psychological morbidity was about 20 , but it might be as high as 50 . Indeed, in some disaster studies, such as the Chowchilla bus kidnapping 50 and the Nazi Holocaust follow-ups, the rates have been 100 . We present these average estimates with caution, however, because, as noted earlier, many of the worst disasters occurred in developing countries 49, 51, 52 and in the former Soviet Union after these reviews appeared. The effects of these devastating disasters appear to be much worse and hence might increase the average figures substantially. For example, the rates of psychiatric morbidity reported in recent studies of natural disasters in Sri Lanka, Colombia, and India were 75 , 55 , and 59 , respectively 53 . The most frequently reported symptoms in adults in the...

Neurobiology of the Fear Response and Learning

Over the years, one thing that I have realized in both my clinical practice and in my academic work is that in order to understand pathological functioning, it is critical to have a firm grasp on what constitutes normal functioning. In the case of PTSD, understanding abnormal or pathological reactions to traumatic stressors involves understanding the typical processes by which the human mind and body respond to fear. For instance, McEwan (1998) proposes that PTSD pathology is the consequence of the normal systems of allostatic maintenance failing to shut off once the load of an actual stressor is gone. Posttraumatic Stress Disorder, then, might be understood as a consequence of the organism's inability to shut off its fear-response mechanisms. Therefore, we cannot understand PTSD without knowing about memory. After all, memory is central to PTSD, either failing to forget danger or being reminded of danger on a relentless and persistent basis. Posttraumatic Stress Disorder is about...

Acute Stress Disorder

The correctional officer in the preceding vignette displays many of the signs and symptoms consistent with Acute Stress Disorder (ASD). She was clearly having a difficult time adjusting after her exposure to the traumatic stressor of witnessing her colleague being murdered. She was not returning to a normal level of functioning, and her levels of stress were problematic enough to cause significant functional impairment. Acute Stress Disorder is sometimes considered the precursor to PTSD. Both of these disorders share a great many symptoms, although ASD includes more dissociative symptoms than PTSD. The main difference between the two is that ASD can only be diagnosed within the first 2 days to 4 weeks after a traumatic stressor, and PTSD can only be diagnosed after 4 weeks following exposure to a traumatic stressor. In essence, ASD is PTSD for 4 weeks after that, if symptoms persist, it becomes PTSD. The main symptom clusters of ASD are the same as for PTSD reexperiencing, avoidance,...

Specific Therapies for Specific Traumas and Adjunctive Treatments

Much of the treatment discussed in previous chapters has been rather generic and relevant to the treatment of PTSD in general. But are all traumas and traumatic stressors created equal To answer this question, one needs only to ask yet another question, Are all patient's the same Certainly not. The development and use of specific treatments for specific types of trauma (e.g., sexual assault, disasters, or combat-PTSD) is the product of at least two phenomena, basic pragmatics of clinical theory and research and the expanding sophistication of clinical science in the mental health field. In order to develop a sound study to test the effectiveness of a particular treatment, the more specific and targeted the population and sample, the better a study will be on methodological and statistical grounds. It is easier to develop a model and a treatment protocol for a small, more circumscribed treatment sample than for an entire population. Further, once such a study is developed and...

Summary

Understanding stress-how it develops, how it is maintained, and how we cope with it-is an important feature of understanding Posttraumatic Stress Disorder. Stress is as much a mental process and subjective experience as it is a physiological process. The consequences of stress can range from minor frustration to significant health and mental health problems. Our ability to successfully cope with stress depends upon a complex interplay between our personalities, mental processes, and environment, including the people around us.

The Amygdalas

These cells then become vulnerable to subsequent stimuli and may suffer atrophy or even die. This influences hippocampal neurogenesis, which is inhibited. These events help explain the memory defects in patients with PTSD or depression. Cortisol also causes damage to the prefrontal cortex, impeding decision-making processes.

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