Posttraumatic Stress Natural Treatment

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Functional Problems In Ptsd

The point of describing what is entailed in a conceptual understanding of a functional analytic case conceptualization is to notice the idiographic nature of the assessment process for the purpose of identifying additional sources of information of variance in problem behaviors to improve clinical outcome. There are many sources about how to conduct and even quantify a functional analysis (e. g., Follette, Naugle, & Linnerooth, 2000 Hawkins, 1986 Hayes, Nelson, & Jarret, 1987 Haynes, 1992, 1998 Haynes & O'Brien, 2000 Haynes & Williams, 2003 Johnston & Pennypacker, 1980 Kanfer & Grimm, 1977 Kanfer & Saslow, 1969 Naugle & Follette, 1998 Nelson & Hayes, 1986). As mentioned above, reviewing the scientific literature about likely sources of control in a particular clinical situation is a typical starting point. In this section we present a few of the symptoms of PTSD and consider them as target behaviors that are the focus of treatment. Most of the symptoms of...

Recommendations from the National Institute of Mental Health National Center for PTSD Conference

In November 1995, 45 clinicians and researchers from around the world met in Boston, Massachusetts, in conjunction with the annual meeting of the International Society for Traumatic Stress Studies, to discuss and debate various approaches to the assessment of PTSD (Keane, Solomon, Maser, & Gerrity, 1995b). Although their task was to provide guidance for conducting clinical research in the field, their recommendations relate to the development of standards for assessing PTSD in many different settings and for a variety of purposes. The conference participants reached consensus on several parameters of the assessment process. Those relevant to the selection of measures to assess PTSD and symptom severity are described below. 2. Structured diagnostic interviews that provide both a dichotomous and continuous rating of PTSD symptoms are preferred. 7. Self-report instruments for PTSD should meet the standards for psychometric instruments established by the American Psychological...

Special Issues in Assessment of PTSD

Several clinicians highlight the importance of considering the different populations on which an assessment instrument for PTSD was validated when selecting a measure. The need to develop instruments that are culturally sensitive has been of great interest for many years as a result of documentation of ethnocu1tural-specific responses to traumatic events. For example, several researchers have provided evidence of differences between people from ethnic minorities and European Americans in the severity of PTSD symptoms experienced following a traumatic event (e.g., Frueh, Brady, & Arellano, 1998 Green, Grace, Lindy, & Leonard, 1990 Kulka et al., 1990). The need for culturally sensitive instruments is further emphasized by the growing awareness among scholars that developing countries have a higher prevalence of PTSD than industrialized nations (De Girolamo & McFarlane, 1996). To date, the psychological assessment of PTSD has developed primarily within the context of Western,...

Posttraumatic Stress Disorder

DSM-IV-TR classifies PTSD as an anxiety disorder with the major criteria of an extreme precipitating stressor, intrusive recollections, emotional numbing, and hyperarousal. Individuals at risk for PTSD include, but are not limited to, soldiers and victims of motor accidents, sexual abuse, violent crime, accidents, terrorist attacks, or natural disasters such as floods, earthquakes or hurricanes.7 PTSD has acute and chronic forms. In the general population, the lifetime prevalence of PTSD ranges from 1 to 12 and is frequently comorbid with anxiety disorders, major depressive disorder, and substance abuse disorders with a lifetime prevalence of comorbid disease ranging from 5 to 75 . PTSD is often a persistent and chronic disorder and a longitudinal study of adolescents and youth with PTSD showed that more than one-half of individuals with full DSM-IV-TR PTSD criteria at baseline remained symptomatic for more than 3 years and 50 of those individuals with subthreshold PTSD at baseline...

Efficacy Of Exposure Therapy For Ptsd

Over the past 15 years many studies have found cognitive-behavioral therapy (CBT) effective in reducing PTSD, making CBT the most empirically validated approach among the psychosocial treatments for PTSD (for reviews, see Foa & Meadows, 1997 Foa & Rothbaum, 1998 Harvey, Bryant, & Tarrier, 2003). The CBT programs that have been empirically examined include prolonged exposure (PE), stress inoculation training (SIT), cognitive therapy (CT), and eye movement desensitization and reprocessing (EMDR). There are more studies demonstrating the efficacy of exposure therapy (including PE) than of any other treatment for PTSD (Foa & Rothbaum, 1998 Rothbaum, Meadows, Resick, & Foy, 2000), and PE has been shown effective in treating PTSD associated with a wide variety of traumas. When directly compared, PE produces results as good as or better than other CBT approaches (CT, SIT, EMDR) or PE combined with components of the other treatments (see discussion below).

Maintaining the Focus of Treatment on PTSD

Clients with chronic PTSD often face multiple life stressors that lead to impaired general functioning. In addition, individuals with chronic PTSD often have comorbid psychiatric and medical problems (e.g., Davidson, Hughes, Blazer, & George, 1991 Kessler et al., 1995). Therefore, crises during treatment are not unusual, especially if early or multiple traumatic experiences have interfered with the development of healthy coping skills. Poorly modulated affect, self-destructive impulse-control problems (e.g., alcohol binges, substance abuse, risky behaviors), numerous conflicts with family members or others, and severe depression with suicidal ideation are common comorbid conditions with PTSD. These problems require attention but can potentially disrupt the focus on treatment of PTSD. If careful pretreat-ment assessment has determined that chronic PTSD is the client's primary problem, our goal is to maintain the focus on PTSD with periodic reassessment of other problem areas, as...

Dissemination Of Pe For Ptsd

Despite the demonstrated efficacy of PE and other exposure therapies for PTSD, clinicians have been slow to adopt the techniques into their practice. Becker, Zayfert, and Anderson (2004) surveyed a large sample of psychologists about whether they treated patients with PTSD and, if so, whether they were trained in the use of imaginal exposure and whether they used it with their patients. Although 63 of the sample reported having treated more than 11 patients with PTSD, only 27 of the sample were trained in the use of imaginal exposure for PTSD and even fewer (9 ) reported regularly using imaginal exposure with their patients suffering from PTSD. Thus few therapists who see patients with PTSD are trained in the use of exposure therapy, and even fewer use it. What are the reasons for this low utilization rate Becker et al. (2004) found that the commonest reason for not using exposure therapy to treat PTSD was lack of training (60 ). The next two commonest reasons were resistance to using...

Does The Ptsd Diagnosis Effectively Classify Symptomatic Persons Posttrauma

When PTSD was established as a diagnosis in 1980, it was not conceptualized as a pathologic response, but rather as a normative response to the abnormal circumstance of extreme trauma. PTSD was considered to represent ''psychopathology'' only in so far as this ''normative response'' resulted in a maladaptive complex of symptoms. The idea behind PTSD was that victims should not need to justify the existence of symptoms or poor social, occupational or interpersonal functioning, because exposure alone explained symptom formation. The framers of the PTSD diagnosis were concerned that, in the absence of this diagnosis, stress-related symptoms had been viewed as transient, and not requiring intensive treatment (reviewed in 6). Thus, the extent to which the diagnosis of chronic PTSD has become an indication of a psychopathologic response to trauma represents a major paradigmatic shift from the original intention of the diagnosis. The PTSD diagnosis was initially proposed in the absence of...

General Mechanisms Whereby Biological Findings In Ptsd Might Reflect A Pathophysiology Of The Disorder

In tandem with observations of the phenomenology and psychology of PTSD, neurobiological examinations of trauma survivors have supported the possibility that the development of PTSD is facilitated by a failure to contain the normal stress response at the time of the trauma, resulting in a cascade of biological alterations that, eventually, underlie the enhanced recall, distress at reminders, avoidance, and hyperarousal symptoms that characterize PTSD. In contrast to the normal fear response, which is characterized by a series of biological reactions that help the body modulate, and gradually recover from stress (e.g., high cortisol levels), prospective biologic studies have shown that individuals who develop PTSD or PTSD-related symptoms appear to have more attenuated cortisol increases in the acute aftermath of a trauma than those who do not develop the disorder 37,38 . Moreover, persons who develop PTSD show elevated heart rates in the emergency room, and at one week post-trauma,...

Implications Of Biological Findings In Ptsd For Strategies Of Pharmacological Prophylaxis

The biological conditions that appear to promote the development of PTSD suggest two promising strategies for pharmacological prophylaxis. The first is to develop interventions aimed at diminishing adrenergic hyperactivity. Two trials have been initiated to date using propranolol for this purpose. Pitman et al. 26 performed double-blind treatment with placebo (n 23) and propranolol (n 18) at doses sufficient to effect beta-adrenergic blockade (40 mg qid) in patients within 6 hours of a psychologically traumatic event. Treatment continued for 10 days and Clinician Administered PTSD Scales (CAPS) were administered to 11 propranolol-and 20 placebo-completers after 1 month. Whereas total CAPS scores did not differ significantly between the treatment groups, the propranolol-treated subjects were significantly less physiologically reactive to traumatic reminders, suggesting that this or a related approach might provide an effective preventative strategy. Vaiva et al. 51 initiated a similar...

Treatment For Circumscribed Ptsd And Empirical Support

The FAP also underlies current popular treatments for circumscribed PTSD. Exposure is the primary behavioral approach to treating clients with problems resulting from trauma (e.g., Foa & Rothbaum, 1997) and is present in all forms of psychological treatment. From a behavioral point of view, all treatments, even ones not classified as behavioral, generally expose clients to traumatic material as part of the treatment process, and their treatments would be consistent with an exposure model. The learning principle underlying exposure is extinction. Extinction occurs when the evocative stimulus is presented and then is not followed by an aversive stimulus. Thus, in clinical work, exposure involves presenting the evocative stimulus and making sure that the client does not avoid or escape it. This process of exposure to traumatic material, although potentially healing in its effects, is by necessity emotionally challenging for the client. In fact, clients who initially experience high...

Symptoms Of Complex Ptsd

The DSM-IV descriptions of PTSD symptoms (American Psychiatric Association, 1994) were developed for problems resulting from circumscribed, physical trauma. The aversive stimuli and the resultant symptoms for such trauma are relatively easy to specify. Furthermore, in order to be diagnosed with PTSD, the trauma has to be remembered. This implies that the clients are able to tolerate anxiety to the extent that they are aware of the traumatic conditioning, attribute their PTSD symptoms to the trauma, and seek treat Many clinicians who work with clients who have histories characterized by repetitive trauma and the associated symptoms refer to this syndrome as complex PTSD (Herman, 1992a). Although symptoms of complex PTSD involve the same aversive conditioning and avoidance behavior that accounts for DSM-IV PTSD symptoms, they are elaborated and more debilitating because the trauma is generally interpersonal and occurred repeatedly over an extended period of time, usually in childhood...

Integrated Treatment of PTSD and Substance Abuse

In practice, however, the two disorders are not usually treated simultaneously. Indeed, it is still the norm for clients to be told that they need to become abstinent from substances before working on PTSD a mandate that does not work for many clients. In many settings clinical staff are reluctant to even assess for the other disorder and clients' own shame and secrecy about trauma and substance abuse can further reinforce treatment splits (Brown et al., 1995). Integration is thus, ultimately, an intrapsychic goal for clients as well as a systems goal to own both disorders, to recognize their interrelationship, and to fall prey less often to the vulnerability of each disorder triggering the other. Seeking Safety provides opportunities for clients to discover connections in their lives between the two disorders in what order the disorders arose and why, how each affects healing from the other, and the origins of both disorders in other life problems (e.g., poverty). The clinician, too,...

Ptsd As A Risk Factor For Retraumatization

Several epidemiological studies have found that after an individual has experienced one high-magnitude stressor, he or she is at risk for experiencing additional traumatic events over the lifespan (Breslau, Davis, Andreski, & Peterson, 1991 Kilpatrick, Saunders, Veronen, Best, & Von, 1987). Of even greater significance is the report that, at least among rape victims, the presence of PTSD, in and of itself, contributes to risk for repeated traumatization (National Victim Center and Crime Victims Research and Treatment Center, 1992). Given these findings, it becomes critical to determine whether individuals abused as children have PTSD related to the childhood abuse and or assault. There has been less than a complete consensus concerning the existence of a diagnostic category that adequately captures the range of symptoms associated with a history of childhood abuse. However, the accumulation of data indicates that PTSD is a salient, if not core, component of the complex of...

Early Post Traumatic Stress Disorder and Clinical Treatment

On the basis of these data, and of clinical experience across the country, one can safely assume that a significant proportion of psychological casualties go undetected and might never come for formal therapy. Two community surveys (see below) indicate that much help is sought from other community resources (e.g., general practitioners, religious authorities) and most help is received within families. An estimate based on 7 years of ER admissions in Jerusalem shows that the rate of PTSD following terrorist attacks is twice as high as that observed in other traumatic events. However, recovery from early PTSD symptoms during an era of terror (2000-2003) is similar to that observed before the current wave of hostilities 3 . Thus, as might be the case in other areas of the world, the interface between the acute response and prolonged disorders is not entirely covered, and there might be a gap in the management of victims during that transition.

Recent Advances in Psychological Assessment of Adults with Posttraumatic Stress Disorder

Originally conceptualized in the DSM-III (American Psychiatric Association, 1980) as relatively rare, traumatic events and posttraumatic stress disorder (PTSD) are now viewed as common across the world. As interest in PTSD grows internationally, so does the need for sensitive and specific diagnostic interviews, questionnaires, and psychological tests. As progress is made in understanding the impact of trauma on psychological functioning, the consistent use of standardized psychological measures will permit cross-study comparisons, meaningful meta-analyses, the specification of conclusions regarding public policy based on sound empirical methods, and the more expeditious use of evidence-based clinical protocols for treatment. The purpose of this chapter is to discuss the various methods for assessing PTSD in a wide variety of settings. Understanding the optimal methods for assessing the presence of PTSD, related psychiatric conditions, treatment outcome, and the monitoring of progress...

Complications And Obstacles For Fap Therapists In Treating Complex Ptsd

FAP therapists are likely to encounter difficulties and emotional barriers similar to therapists of any other orientation when treating clients with complex PTSD. However, because FAP invites consideration of intense emotional experience that is actually focused on interactions that occur in the here and now of the session, both client and therapist may have stronger reactions than in other types of therapy. Because FAP typically leads to more intense connections between therapists and clients, we will discuss common pitfalls and complications may also arise these we discuss below.

Specific Mechanisms Potentially Contributing To The Pathophysiology Of Ptsd

Stimulation, in synergy with other neuropeptides, such as arginine vasopressin, resulting in a higher magnitude adrenocorticotropin hormone (ACTH) response, which in turn might further stimulate the sympathetic nervous system through a direct effect 42 . Moreover, since glucocorticoids inhibit norepinephrine release from sympathetic nerve terminals, relatively lower cortisol levels may be expected to prolong norepinephrine availability at synapses, both in the periphery and in the brain 43 . Importantly, enhanced negative feedback inhibition may be present at the time of the trauma (i.e., may be a pre-trauma risk factor), and may contribute to the premature suppression of ACTH and cortisol among individuals at increased risk for the development of PTSD in response to trauma 44 . There may be consequences of increased catecholamine levels in the acute aftermath of a trauma in promoting the consolidation of the traumatic memory. Indeed, adrenergic activation in the presence of low...

Biological Risk Factors Contributing To Ptsd

If there is a predisposing biology of PTSD, it appears to comprise a set of conditions that impede an individual's ability to contain the stress response. According to the cascade described above, trauma exposure will further the development of these conditions and consequences, resulting in a progressive sensitization to subsequent trauma exposures. It is conceivable that any one of a number of biological conditions could have the effect of stimulating or sustaining heightened levels of physiological arousal, and consequently distress, at the time of the traumatic experience, and thereby, of facilitating a biological sensitization to subsequent traumatic events. PTSD has been associated with numerous other biological alterations, including, for example, those affecting immune function 46 , catecholami-nergic regulation 47 , psychophysiologic responsivity 48 , and changes in sleep architecture 49 , each of which could be studied prospectively and in high-risk samples. Furthermore,...

Does Asd Predict Ptsd

There are now 12 prospective studies of adults that have assessed the relationship between ASD in the initial month posttrauma and development of subsequent PTSD (Brewin, Andrews, Rose, & Kirk, 1999 Bryant & Harvey, 1998 Creamer, O'Donnell, & Pattison, 2004 Difede et al., 2002 Harvey & Bryant, 1998a, 1999b, 2000a Holeva, Tarrier, & Wells, 2001 Kangas, Henry, & Bryant, 2005 Murray, Ehlers, & Mayou, 2002 Schnyder, Moergeli, Klaghofer, & Buddeberg, 2001 Staab, Grieger, Fullerton, & Ursano, 1996). In terms of people who meet criteria for ASD, some studies have found that approximately three-quarters of trauma survivors who display ASD subsequently develop PTSD (Brewin et al., 1999 Bryant & Harvey, 1998 Difede et al., 2002 Harvey & Bryant, 1998a, 1999b, 2000a Holeva et al., 2001 Kangas et al., 2005 Murray et al., 2002). Compared to the expected remission of most people who display initial posttraumatic stress reactions, these studies indicate that the ASD...

Cognitive Models Of Ptsd

Information-processing theory has been widely used to understand the development and maintenance of anxiety disorders, including PTSD (Lang, 1979, 1985). This theory suggests that emotions, such as fear, are encoded in memory in the form of networks, where representations of anxiety-provoking events are stored. Fear networks are hypothesized to contain three important types of information (1) information about the feared stimuli or situation (2) information about the person's response to the feared stimuli or situation and (3) information about the meaning of the feared stimuli and the consequent response. Foa and Kozak (1986) posited that the fear networks of individuals with PTSD differ from the fear networks of individuals with other anxiety disorders in three ways. First, the fear network of individuals with PTSD is larger because it contains a greater number of erroneous or inaccurate connections between stimulus, response, and meaning elements. Second, the network is more easily...

The Fear Structure of PTSD

Foa, Steketee, and Rothbaum (1989) proposed that a traumatic event is represented in memory as a fear structure that is characterized by a large number of harmless stimulus elements erroneously associated with the meaning of danger. These erroneous associations are reflected in the perception of the world as entirely dangerous. In a further development of emotional theory for PTSD, Foa and Jaycox (1999) suggested that the physiological and behavioral responses that occurred during and after the event, including the PTSD symptoms themselves, are interpreted as signs of personal incompetence, leading survivors to the erroneous perception about themselves as entirely incompetent. The erroneous cognitions about the world and the self underlie PTSD symptoms, which in turn reinforce the erroneous cognitions in a vicious cycle (for a more detailed discussion, see Foa & Rothbaum, 1998). PTSD symptoms are further maintained by cognitive and behavioral avoidance strategies that prevent...

Fap An Ideal Behavioral Therapy For Complex Ptsd

In theory, the treatment for complex PTSD involves the same exposure-based procedures described for circumscribed PTSD. That is, the evocative stimuli need to be identified and described, the client must be willing to expose him- or herself to these stimuli and not avoid or escape from them, and the stimuli should be presented in vivo. Because complex PTSD involves difficult-to-describe evocative stimuli, however, it is difficult to devise an in vivo exposure treatment that presents the evocative stimuli but then also blocks avoidance behavior. The stimuli involved in complex PTSD are rarely specific things or events. Further complicating the situation is the fact that there are times when the client cannot remember the trauma, or the longer-term, delayed effects are diffuse and do not formally resemble the behavior that occurred during the trauma itself. For example, the behavior during the original classical conditioning might include the experiences of pain, fear, and numbing out....

Assessment Of Ptsd

Increasingly, clinicians have come to recognize that a substantial portion of their patients have experienced traumatic events and may require treatment for PTSD. Additionally, patients who seek treatment for medical or psychiatric disorders other than PTSD may have a presentation that is complicated by the presence of PTSD. Thus clinicians are interested in the proper assessment and evaluation of patients with PTSD. Clearly, PTSD is assessed for many different reasons, and the goals of a particular assessment will determine the methods selected by the professional. The objective of many mental health clinicians is a diagnostic evaluation that includes a differential diagnosis and other information that is helpful in treatment planning. Other practitioners may be involved in forensic evaluations for which diagnostic accuracy is of paramount importance. Researchers involved in epidemiological studies may be interested in the rate of occurrence of PTSD and its associated risk factors...

Ptsd

The rates of PTSD are very dependent on the sampling used in a study as well as the severity and nature of the event. Therefore, each new disaster should be considered as a novel event and predictions about the rates of morbidity should depend on careful consideration of which group of victims are being considered as well as the time that has elapsed following the disaster. The Buffalo Creek disaster (dam break), which occurred in 1972, is one of the best studied disasters a 59 PTSD lifetime rate was found among the victims, with 25 still meeting PTSD criteria some 14 years after the event 17 . One of the highest rates was demonstrated by Goenjian et al. 57 following the Armenian earthquake, with 67 meeting PTSD criteria 18 months after the earthquake. In a study conducted 1 to 4 months after Hurricane Andrew 72 , 33 met the criteria for PTSD. However, in some studies of low-exposure groups, the rates of PTSD are sometimes little different from the prevalence in the general population...

The Role Of Disaster Research

Large-scale traumatic events impact on social and personal attitudes and have the potential to bring about major, yet sometimes subtle, shifts in societies. Hence, in the aftermath of a disaster, there is a potential for major changes in public and professional attitudes because of the lessons learned by a small group of individuals involved in disaster relief and public administrators. In the longer term, these changes can be instrumental in

The Prevalence Of Disasters

The emergence of a more general interest in post-traumatic stress disorder (PTSD) since the publication of DSM-III 35 has led to a dramatic increase in the attention to the impact of disasters. In the past, these events were believed to be outside the range of normal human experience, but systematic examination has now shown that they are more common than previously thought. Norris 19 , in a study of 1,000 adults in southern United States, found that 69 of the sample had experienced a traumatic stressor in their lives and this included 21 in the past year alone. In this year, 2.4 of households in the southern United States were subjected to disaster or damage, with a lifetime exposure to disasters of 13 . Kessler et al. 36 , in a stratified population sample in the USA, found that 60.7 of males and 51.2 of females had experienced an event that met the DSM-IV stressor criterion. 18.9 of men and 15.2 of women had been exposed to a natural disaster, with the respective rates of lifetime...

How Do We Know Whether A Response To Trauma Is Pathological In Its Immediate Aftermath

Five to eight weeks after the attacks, a prevalence rate of 7.5 of randomly sampled subjects living south of 110th Street had reportedly developed symptoms of post-traumatic stress disorder (PTSD) 1 , with those having the most severe exposure or personal loss at higher risk than others. When another randomly sampled group taken from the same cohort was studied 6 months after the attacks, only 1.7 demonstrated PTSD 2 . Certainly one can conclude from these findings that there was recovery of the New York community as a whole from the initial effects of the September 11 attacks. Two important questions are raised by these findings. First, did the clinical symptoms contributing to the initial estimates of PTSD constitute a real clinical syndrome requiring treatment, or simply reflect temporary distress rather than mental illness Second, would the smaller group with persistent symptoms be identifiable immediately post-trauma

What Kind Of Responses To Trauma Should Mental Health Practitioners Be Concerned About

In most discussions of long-term pathologic responses following a traumatic event, there is an implicit assumption that the critical outcome being referred to is PTSD. Yet, PTSD is but one among several possible outcomes following trauma exposure. Trauma survivors, compared to persons who have not experienced trauma, are at increased risk for the development of other mental disorders, such as major depression, panic disorder, generalized anxiety disorder, and substance abuse, as well as persistent anxiety symptoms and distress that do not meet criteria for a specific psychological disorder 3 . Furthermore, they are at risk for developing somatic symptoms and physical illnesses, particularly hypertension, asthma, chronic pain syndromes and other psychosomatic illnesses. Interestingly, the focus of most investigations in the wake of disasters that affect large numbers of persons, whether they be natural or man-made events, has been related to PTSD, even though this disorder is neither...

Core Predictors Of Chronic Dysfunction In The Acute Phase

Following a traumatic event is associated with the later development of PTSD. However, greater symptom severity from 1 to 2 weeks post-trauma and onwards has been positively associated with subsequent symptom severity 7 . On the other hand, it is fairly certain that persons with low symptom levels in the immediate aftermath of a traumatic event are not at risk for the development of subsequent PTSD. These findings are consistent with the idea that PTSD as a psychopathologic process reflects a failure of recovery. Numerous studies have found a relationship between peri-traumatic dissociation and the subsequent development of PTSD (e.g., 5,8-10). One recent meta-analysis reported that peri-traumatic dissociation was the single best predictor (r 0.35) of subsequent PTSD development among trauma-exposed individuals 11 . However, this association has not been a consistent finding 12-15 and, when present, has often been attributed to the effects of covariate interactions 16,17 . Prospective...

Pretrauma Risk For The Development Of Posttraumatic Mental Health Problems

Although being able to predict potential long-term pathologies from the acute response, such as peri-traumatic panic, is important, understanding the development of psychiatric disorders post-trauma will ultimately involve an appreciation of risk factors for those early responses. The finding that only a proportion of those exposed to trauma develop short and long-term symptoms justifies an exploration of the factors that increase the risk for, as well as those that might serve to protect individuals from, developing symptoms following trauma exposure. While the concept of risk can be used to describe characteristics of a trauma that make an event more or less likely to result in symptoms, or to describe the specific nature of the response to a trauma that may predict persistent symptomatology, as in the preceding discussion, it is equally used to describe characteristics of the persons who undergo a traumatic experience that make them more likely to develop post-traumatic...

The Role Of Biological Studies In Helping To Identify Pathological Responses

Biological findings in PTSD have become increasingly relevant to the issue of the identification of psychopathology. Initially, the biology of stress and the stress response was adopted as a relevant model for the study of PTSD. This assumption provided the intellectual justification for interpreting PTSD as one manifestation along a continuum of ''normal'' responses to adversity. Although a comprehensive review of the neurobiology of PTSD is beyond the scope of this chapter, the results of neurobiological studies of PTSD pertain directly to the issue of the identification of PTSD as a pathological or non-normative response to trauma. Most relevant to this discussion are the repeated observations and nature of a distinct set of biological alterations associated with PTSD symptoms (see 36). At least some of the biological alterations that have been observed reflect changes in stress-responsive systems (e.g., the hypothalamic-pituitary-adrenal axis) that are quite different from what...

Cognitivebehavioral Interventions

A large number of studies have examined the effectiveness of cognitive-behavioral interventions in preventing or treating PTSD or ASD. Foa et al. 48 reported on the preliminary findings of a therapeutic intervention intended to prevent the development of PTSD in female rape and assault victims. The intervention consisted of four 2-hour sessions. During the first meeting, the therapist introduced the program and gathered information about the subject's symptoms and distorted beliefs related to the disruptive experience they suffered. Also, a list of avoided people and or situations was generated. In the second session, this list was organized into a hierarchy based on the level of anxiety each item produced. The person was trained in relaxation and deep breathing and then asked to recall the experience (imaginal exposure). The therapist led the person to examine the accuracy of his her beliefs through oriented questions (cognitive restructuring). This dialogue was audiotaped and the...

Eye Movement Desensitization And Reprocessing

Eye movement desensitization and reprocessing (EMDR) is a technique developed by Shapiro 50 on the basis of the observation that lateral eye movements facilitate cognitive processing of traumatic material. It is a form of exposure (desensitization) with evident cognitive components accompanied by rhythmic eye movements. Designed originally as a treatment for traumatic memories, it was called eye movement desensitization (EMD). Its essence was as follows. After identifying a traumatic target memory, the therapist asked the patient to articulate a self-referent negative cognition associated with the memory and a positive cognition to replace the negative one. The therapist then moved his her fingers back and forth in front of the patient's eyes, instructing the patient to track his her fingers visually while concentrating on the distressing memory. After each set of 10-12 eye movements, the therapist asked the client to provide ratings of distress and strength of belief in the positive...

Psychoanalytically Oriented Psychotherapy

Lindy used brief psychoanalytic psychotherapy techniques to treat PTSD 56 . His therapy has three main elements (a) therapeutic alliance (b) disclosure and interpretation of transference (c) detection and therapeutic use of counter-transference. According to Lindy, the disruptive event damages the patient's perceptive capacity negatively, affecting his her reality judgment. The analyst must bring the patient's attention to those

Delayed and Chronic Period

Cases of acute stress and post-traumatic stress that occur during the post-immediate phase may resolve - spontaneously, or with treatment - fairly rapidly (in less than 3 months). However, they may also persist, and even become chronic. The typical clinical picture of PTSD may then become It is worth noting that the above criteria (c) and (d) together reproduce the personality changes that were described in the former European diagnostic category termed ''traumatic neurosis''. According to Fenichel, this personality change was characterized by the blocking of such functions of the ego as (a) filtering of the environment (b) presence (c) relationship with others. Briefly, the victim no longer has the same relationship with others and the world since the traumatic event. He has developed a new way of perceiving, thinking, loving, wanting, and acting. In addition to PTSD, ICD-10 provides another diagnostic category entitled ''enduring personality change after catastrophic experience''...

History Of Mental Health Interventions After Disasters

The detection and treatment of mental disorders caused by disasters began in the USA, thanks to the advent of the PTSD diagnostic category in the aftermath of the Vietnam War, and the subsequent application of this diagnosis to civilian situations. A literature survey 12 revealed that a great variety of treatment methods have been proposed at different times. Treatment has been offered to victims 13,14 , relatives and other community members 15,16 , or rescuers 17,18 . The usefulness of treatment was accepted only gradually in the community, and Lindy 19 mentions that the main difficulty was gaining access to victims. As early as 1983, Mitchell 20 defined debriefing procedures, on the basis of cognitive techniques. His method aimed at treating police officers or firemen who had been exposed to a critical event. Mitchell's method can be applied during the post-immediate period (first week) it follows a seven-step procedure (introduction facts thoughts reactions symptoms education...

What Types of Mental Disturbances

The types of disorders occurring during and after disasters have been reviewed above. Briefly, the immediate phase may be associated with distressing symptoms accompanying adaptive stress symptoms of mal-adaptive stress, such as confusion, agitation, panic flight, automatic behavior and, exceptionally, neurotic or psychotic reactions the post-immediate phase may be characterized by a return to normal health, or by the insidious onset of a post-traumatic syndrome (PTSD or PTSD-like) the chronic phase may present with the persistence of PTSD, or personality changes.

Longterm Health Consequences

Among the major problems affecting the victims are psychological difficulties resulting from isolated life in temporary housing. This isolation and the loss of community sometimes have led to tragedies such as suicides and so-called solitary death (unattended death in temporary housing). More than 250 cases of solitary death have been reported among victims of the earthquake. This has become a major social concern among the population in Kobe and a reason to blame the local government. Lack of local health personnel was cited as one of the contributing factors for this tragedy. According to our study on schoolchildren, psychological effects have been marked among girls of a younger age who lost families and friends. Neurotic symptoms decreased after 6 months but depressive symptoms and physical complaints continued even after 12 months 7,8 . A few articles from the Kobe area report a relatively low prevalence of post-traumatic stress disorder (PTSD) among victims compared with data in...

Studies On The Mental Health Consequences Of The Earthquake

A study of survivors evaluated at 4 to 6 months after the earthquake revealed a prevalence of post-traumatic stress disorder (PTSD) of 76 3 . In another study conducted in the epicenter (Golcuk), 1,000 survivors were screened PTSD was diagnosed in 43 of the group, and 31 were diagnosed as having major depression. Risk factors included high trauma exposure, great loss of resources, difficult post-disaster living conditions and the continuing experience of aftershocks 4 . In another study by the same group, 586 survivors were evaluated 20 months after the earthquake the rates of PTSD and major depression were 39 and 18 respectively 5 . A study conducted at 6 to 9 months after the disaster in Kocaeli emphasized the importance of psychiatric conditions comorbid with PTSD 38.3 of the subjects with a diagnosis of PTSD had another psychiatric disorder major depression, generalized anxiety disorder and panic disorder were the three most frequent diagnoses 6 . Having this information about...

Impact Phase And Early Actions

Primary aims of these units were to provide pertinent information, relief from the traumatic experience and or crisis intervention to the victims upon their request. The goal of intervention was not simply the prevention of post-traumatic stress disorder (PTSD), but also the management of acute stress reactions, grief, depression, and a host of other maladaptive psychological and behavioral responses according to the individual needs of the victims. Psychological care included mainly listening to the victims while they were referring to their personal experiences and ventilating their emotional overcharge, in addition to prescription of anxiolytic and or antidepressant medication whenever needed. Also, particular emphasis was given to fostering resilience by providing coping skills training at an elementary level and education about the expected stress response, traumatic reminders and normal versus abnormal functioning. Anxiety

Early Postimpact Stress Reactions

In addition to properly addressing the aforementioned presenting complaints, 102 subjects were fully investigated through a checklist of sociodemographic variables and a semi-structured psychiatric interview focusing on the detection of acute stress reaction (ASR) and PTSD. This interview was devised according to the ICD-10 Research Diagnostic Criteria and consisted of 35 items pertaining to the ASR diagnosis and 10 items pertaining to the PTSD diagnosis. Items were ascertained dichotomously as either present or absent. More specifically, the 35 items assessing ASR were grouped into the eight symptom clusters described in the ICD-10 (i.e., autonomic arousal symptoms, symptoms involving chest and abdomen, symptoms involving mental state, general physical symptoms, symptoms of tension, dissociative symptoms, other ''psychic'' symptoms, and other nonspecific symptoms of stress response), while the 10 items referring to PTSD assessed the presence of symptoms of persistent ''reliving'' of...

Psychological Debriefing

Over the last 20 years, it has become customary and then almost mandatory to apply early intervention after disasters and other traumatic events, in the hope of accelerating the resolution of trauma-associated symptoms. Early interventions are intuitively appealing and appear to be a response to a perceived need, but whether or not they are useful remains unclear. Debriefing has become increasingly popular as a treatment for victims of a wide range of traumatic events, from violent crime to natural disasters. In some circumstances and in certain occupations it has become mandatory. Organizations which routinely send their employees into potentially traumatizing situations are compelled to use it in order to protect the health of employees and minimize the impact of litigation seeking compensation. In recent years, studies have, in fact, shown that the procedure has no positive effect on post-traumatic stress symptoms. One study found no difference between victims of motor vehicle...

Closer Look At A Prefabricated Village In Adapazari

The Psychological Support and Psychiatric Treatment Project for Psychological Problems Caused by the Earthquake in Adapazari (ADEPSTEP) was started because of this inadequacy, 5 months after the earthquake, by a group of mental health professionals from two major psychiatric departments in Istanbul. The main objective of the project was to assess the traumatized population for their potential risks for psychiatric morbidity, and to provide treatment and follow-up for 12 months. The population that was assessed (n 350) was severely traumatized. It was a low-income group, with a mean age of 38.4 years, and a high level of personal and material loss (39.4 had lost a close relative). In the clinician-assessed group (n 187), 75.3 were diagnosed as having PTSD. In the PTSD group, 70.8 were female. The major problem in conducting the project was the difficulty in following up regularly the individuals who received a diagnosis of PTSD, since the population of the prefabricated village was...

Treating Direct Survivors Acute Psychological Responses

Systematic debriefing has been attempted in some settings but is far from being accepted by all. Help at this early phase is generally conceived as ''stress management'' and mainly consists of optimizing early recuperation, reducing secondary stressors and providing soothing human contact and support for natural helpers (e.g., families). There are no data showing any relationship between these interventions and subsequent rates of post-traumatic stress disorder (PTSD), and the general belief is that early stress management and the prevention of PTSD are two separate matters. Survivors are often provided with advice and contact phone numbers, often to the same therapist or group of therapists that saw them in the ER. Criteria for release from ERs consist of having attended to and reduced uncontrollable dissociative states, assuring continuity of care by informed family members and having

Communities Under Stress

Beyond direct victims, terrorism affects communities at large. Published work by Bleich et al. 4 suggests that almost half of Israeli residents have been exposed to traumatic events emanating from terrorism, either directly or via friends and relatives (Table 15.2). About 60 felt that their lives were in danger and 58 disclosed being depressed. Nonetheless, and Table 15.2 Traumatic events emanating from terrorism telephone survey of a representative sample of 512 Israelis 4 PTSD symptoms PTSD by symptom criteria alone PTSD by symptoms and distress impairment PTSD Post-traumatic stress disorder. paradoxically so, 82 were optimistic about their personal future. The rate of clinically significant PTSD was surprisingly low (2.7 ), and mostly consisted of females (87.5 ). The study found no association between PTSD symptoms and objective threat. The extent to which PTSD symptoms are the right identifiers of population in distress has been debated (e.g., 5). In the reality of continuous...

Teachers As Therapists

According to reports of the Ministry of Health of B-H, only approximately 100 mental health professionals remained in the city of Sarajevo to serve its 60,000 children who were exposed to war trauma. This disproportion between the number of mental health professionals and the children needing psychological help created a necessity to train lay therapists. Consequently, we developed a model to train teachers in diagnosing and treating children suffering from PTSD and comorbid conditions. During the siege of Sarajevo, it was estimated that approximately 5,000 teachers remained. They provided an effective pool of sophisticated workers who could be trained in detecting and treating PTSD and other comorbid conditions.

After Disaster a Need for Mental First

Research into psychiatric morbidity after a disaster is also necessary. Systematic screening of children and adults for PTSD can provide critical information for rational public mental health programs after a disaster. Early detection of post-traumatic reactions is important, since timely intervention may prevent poor adjustment and a chronic outcome. Research into psychiatric morbidity following disasters can provide a more general insight into the process of coping and the etiology and course of psychiatric illness in general. It also extends our knowledge and improves clinical care in this field of human distress. However, since trauma and disasters often strike suddenly and unexpectedly, we should be prepared before disaster strikes.

Psychiatric Disorders Related To Trauma And Disaster

We are only in the infancy of understanding why some people exposed to traumatic events develop post-traumatic psychopathology and some people do not (for a meta-analysis of predictors of PTSD, see 26). Post-traumatic psychiatric disorders are most often seen in those directly exposed to the threat to life and the horror of a traumatic event. The greater the ''dose'' of traumatic stressors, the more likely an individual or group is to develop high rates of psychiatric morbidity. Certain groups, however, are at increased risk for psychiatric sequelae. Those at greatest risk are the primary victims, those who have significant attachments with the primary victims, first responders, and support providers 27 . Adults, children, and the elderly in particular who were in physical danger and who directly witnessed the events are at risk. Those who were psychologically vulnerable before exposure to a traumatic event may also be buffeted by the fears and realities of, for example, job losses,...

History

The study of emotional reactions to disasters began with observations of the oldest human-made disaster, war. In the United States during the American Civil War, combat psychiatric casualties were thought to be suffering from nostalgia, which was considered to be a type of melancholy, or mild type of insanity, caused by disappointment and longing for home 5 . This was also known as soldier's heart''. In World Wars I and II, terms such as shell shock'', battle fatigue'', and ''war neuroses'' were more common descriptors of the emotional responses to trauma 6,7 . The ''thousand-mile stare'' described the exhausted foot soldier on the verge of collapse. The symptoms of combat stress varied with the individual and the context but included anxiety, startle reactions and numbness 8 Some of the earliest descriptions of what is now referred to as PTSD came from traumatic injury. For example, in 1871 Rigler described the effects of injuries caused by railroad accidents as ''compensation...

Conclusions

Psychological behavioral and psychiatric responses to trauma and disasters have a predictable structure and time course. For some, however, the effects of a disaster linger long after its occurrence, rekindled by new experiences that remind the person of the past traumatic event. Even normal life events can cause anxiety and bring to mind a destroyed home or deceased loved ones. The factors influencing resilience and vulnerability to catastrophic events are only now being identified. Although a growing number of studies have investigated psychiatric response to disaster, more empirical research is needed to determine effective treatments for PTSD.

Risk Factors

The effects of exposure are exemplified by Weisaeth's study of a factory disaster 76,80 . He showed that mortality and injuries were dependent upon the distance from the explosion and this in turn correlated strongly with the later development of PTSD. In the high-exposure group, PTSD prevalence rates were 36 after 7 months, 27 after 2 years, 22 after 3 years and 19 after 4 years. This contrasted to the medium-exposure group, where there was a decrease in the PTSD rate from 17 after 7 months to 2 after 4 years. Thus, the intensity of the stressor not only accounted for the initial prevalence but also for the possible duration of the symptoms. He found that for employees who witnessed the event, even at a close distance, premorbid sensitivity played an important role in the development of symptoms, highlighting the interrelationship between vulnerability factors and exposure. This is a complex issue from both a clinical and research perspective. There are many components of disasters...

Other Risk Factors

It appears that women are at greater risk of psychological distress, measured by a range of outcomes, when exposed to disasters, with the exception of alcohol abuse, where rates are higher in males 17 . These findings are similar to those from general population studies 36 highlighting the relative vulnerability of women when exposed to traumatic events. Although it is difficult to draw conclusions, it appears that women, in general, may be at higher risk of anxiety disorders. bonded relationships. The psychological state of mothers appears to be particularly important in terms of the psychological outcome of children 104 . The nature of family interactions is particularly detrimental for the child, if there is overprotection and lack of emotional warmth. These effects are particular likely to follow if the mother is more irritable as a consequence of PTSD. The mothers' distress and anticipation of danger appear to convey a negative sense to the children, that is manifest in their...

Postimmediate Period

Either the mental state returns to normal in a few days (neuro-vegetative and psychological symptoms subside, the individual is no longer entirely preoccupied by the event and can resume his previous activities), or a psychotraumatic syndrome appears, characterized by the re-experience of the event, avoidance of stimuli reminiscent of the trauma, hyperreactivity, and constant preoccupation with the trauma. Psychotraumatic symptoms may appear only after weeks, or months. This is the so-called ''latency period'', which had been identified in traumatic neurosis by Charcot and Janet, and called period of incubation, contemplation, meditation or rumination. The duration of this period is variable each individual needs a different amount of time to organize new defense mechanisms. Furthermore, if the individual is still hospitalized, he may wait till he recovers his autonomy to start coping with the trauma. ICD-10 and DSM-IV propose the diagnostic term ''post-traumatic stress disorder''...

What We Have Learned

Post-Traumatic Stress Disorder The concepts of ASD and PTSD are not adequate to cover the full range of trauma-related psychological problems 13 . Studies at the Psychological Care Center of Hyogo Prefecture have demonstrated that, among 1,956 cases seen at the Center after the earthquake, those with the full PTSD syndrome according to DSM-IV were 2.5 . However, the prevalence was 4.5 among those who lost their homes, and 13.1 among those who lost their family members 14 . The prevalence of PTSD was clearly related to the severity of damage such as loss of home and loss of family. However, the complete picture of PTSD so far has been fairly rare among the victims in Kobe. There may be many reasons and possible interpretations for the low rate of PTSD among the victims in Kobe. One explanation is the low reporting of PTSD symptoms victims might have had some reservations in reporting such symptoms as dissociation to medical professionals due to the stigma attached to mental symptoms. A...

Pregnant Women

Startled more easily and slept worse. Whereas this could be a reflection of maternal hyperarousal, and part of maternal PTSD, it was an interesting observation as it was a spontaneous observation by experienced mothers. It raises interesting questions regarding maternal exposure to stress and PTSD in the offspring.

Lessons Learned

Factors associated with post-traumatic stress syndrome (PTSS) (our approximation of post-traumatic stress disorder, PTSD), were female gender, unmarried status, less education being outside during the blast, seeing the blast, injury, not fully recovering from injury feeling afraid, helpless, or threatened at the time of the blast not talking with a friend or workmate about the blast bereavement experiencing or anticipating financial difficulty after the blast, inability to work because of injury, and receiving material or financial assistance. Notably, there was no significant association with PTSS symptomatology for age, number of children, religion assessment of hospital care or immediate medical response receiving counseling, or the relationship of the person mourned. The data show a strong link between injury and PTSS (p< 0.0001).

Discussion

The question of research following a major disaster is complex as it involves both moral and scientific considerations. Delay in initiating data collection limits opportunities to obtain early information needed to understand mental health effects of disaster. Secondly, if researchers do not act quickly, important data may be lost forever. It is for these reasons that we decided to put in place a research and documentation team, which among other things developed a 57-item self-administered questionnaire, capable of generating the DSM-IV diagnosis of PTSD. In so doing we were fully cognizant of the fact that conducting methodologically solid investigations of mental health is extraordinarily difficult in the chaotic and complex settings of disasters, particularly those associated with terrorism. Some might disagree.

Research Studies

As a full-time academic researcher, I immediately planned for and obtained human subjects institutional review board approval from New York University to conduct several surveys throughout New York City. The first of these protocols 3 was a systematic survey of randomly selected adults throughout New York City. These individuals were approached by psychiatrically trained interviewers who requested their participation in answering a questionnaire about their physical and mental health prior to and 3-6 months subsequent to the event. Various stresses were recorded, such as their proximity to and involvement in the events of September 11, whether they lost close relatives or friends, and specifically questions about anxiety, depression and the symptoms of PTSD. Each of the 17 items on the Davidson Trauma Scale 4,5 was scored from 0 to 4 for both frequency (0 none to 4 every day) and severity within the past week (0 not at all distressing to 4 extremely distressing). A total score was...

Research Data

During the siege of Sarajevo, we collected data on 791 children randomly selected from 10 schools of one school district 1 . The students were administered the following instruments the Children Post Traumatic Stress Reaction Index, the Impact of Events Scale, the Children Depression Inventory (CDI) and the General Information Questionnaire. The sample was divided into two groups, using a cut-off age of 13 years, to determine whether adolescents as a group respond differently to the events around them by reason of their being in a different stage developmentally and cognitively. war. These children showed more avoidance and re-experiencing symptoms than the group that did not have loss of a family member. This group was also more depressed. 76 of students felt deprived of food, 48 felt deprived of clothes, 29 felt deprived of water and 10 reported that they were deprived of shelter. The rate of post-traumatic stress disorder (PTSD) as a whole was higher in the deprived group when...

Research

The available epidemiological evidence suggests that although 38 of the population is exposed to severe stresses, only about 9.2 ever experience post-traumatic stress disorder (PTSD)-like reactions 8 . The PTSD construct is rather complex and still controversial, and complicated by the issue of vulnerability. In our study of stress and PTSD, we found that the latter disorder was diagnosed in 29.2 of refugees 2 . Most of the refugees examined had multiple traumas, such as combat, injury, loss of a family member, forced labor, witnessing of torture, sexual abuse or imprisonment. In addition to PTSD, other disorders were also registered, such as adjustment disorder (18.6 ), mixed anxious-depressive disorders (11.3 ), and depressive episodes (5 ). The highest prevalence of PTSD was found among the group of refugees who experienced sexual abuse (56 ) and severe forms of torture during detention (74.8 ) 9 . According to another study 10 , a significant number of civilians (11 ) had...

Protective Factors

More frequent in those who developed symptoms following a disaster. In other words, individuals who did not develop symptoms after a disaster reported fewer coping behaviours than those who did develop symptoms. Such findings highlight the problems of identifying protective factors in the aftermath of traumatic events, when reporting is contaminated by the presence of symptoms. Wessely 109 reviewed the literature about the prior screening of troops in World War II and found that many of the characteristics that were thought to be markers of vulnerability had little predictive ability. A study of twin pairs in the US services at the time of the Vietnam war found that there was a genetic vulnerability to PTSD and this was related to personality 110 . The roles that individuals chose in the military were predicted partly by their genetically determined temperamental traits, such as novelty seeking. Individuals with this personality trait were more likely to choose roles that exposed them...

Promoting Individualized Assessment

Our main rationale for developing this text is the idea that clinicians should base treatment on a detailed assessment of their client's unique individual needs, rather than simply administering a structured treatment package. Cognitive-behavioral assessment of PTSD and other trauma-related problems remains centered on a functional analysis of behavior, outlined in Chapter Two by Follette and Naugle. Their approach is that there is no average patient. It is necessary to develop an individualized understanding of the functional relationships among a person's behaviors, life conditions preceding the trauma, how those factors are maintained after the trauma. For the clinician wrestling with trying to understand a complex human being in a set of complex social environments, these authors' emphasis on identifying important, controllable, and causal factors is critical what are the specific variables that, when changed, will lead to large improvements in the behaviors of clinical interest,...

Tools For Traumarelated Problems

Cognitive-behavioral treatments are built around a set of fundamental helping procedures that target different sets of problems encountered by trauma survivors. These are (1) coping skills training, that focuses on teaching clients to respond effectively to the many situation-specific challenges associated with PTSD and other trauma-related difficulties, and to replace existing maladaptive responses with more effective ones (2) prolonged exposure, that works to reduce conditioned fear responses connected with trauma memories and the stimuli that elicit them (3) cognitive therapy, that assists survivors in modifying ways of thinking that create distress and interfere with recovery and (4) acceptance methods, which recognize that some of the problems of A primary feature of most treatments for PTSD is to educate clients about the disorder and the rationales for treatment. Treatments focus on providing information and teaching new skills for living. Those who deliver cognitive-behavioral...

Attending To Interpersonal Processes In Treatment

Behavioral psychology has, of course, a rich history of attention to the interpersonal context of behavior problems, a focus that is seeing increasing development related to PTSD. In this book, interventions that focus on couples concerns are described in Chapter Fourteen by Leonard, Follette, and Compton. Deblinger, Thakkar-Kolar, and Ryan in Chapter Sixteen describe interventions that work conjointly with both children and parents in addressing child traumatic experiences. Group psychotherapy, an important component of treatment for many trauma survivors, is reviewed in Chapter Fifteen by Foy and Larsen. The latter authors point to the advantages for trauma survivors, whose experiences so commonly involve social isolation, social alienation, perceptions of being ostracized from the larger society, shame, and diminished feelings for others, of working toward recovery with other survivors.

Responding To The Needs Of Clinicians

Dealt with well by the principal orientation. In the present volume, many of the authors speak to the capacity for integration of their approaches with other treatments. Walser and Hayes state that if research indicates that a client's problems would be better treated by a different approach, that latter treatment should be implemented first or integrated into the course of ACT. DBT and Seeking Safety are designed to be frontline stages of treatment for individuals with PTSD, so as to get the client stabilized prior to introducing exposure treatment. Najavits has explored how to integrate trauma processing therapy with Seeking Safety. Kubany and Ralston introduce a variety of ways to understand and challenge trauma-related guilt. Awareness of the role of guilt, and Kubany and Ralston's interventions, would be combined with other treatments not designed to systematically address guilt. An element that Monson and Friedman touch on is that psychopharmacological treatments can either help...

Posttraumatic Reactions Long Recognized But Variably Labeled

Documented human history is replete with descriptions of individual reactions to traumatic events. For example, a survivor of the Great Fire of London in the 1600s wrote in his diary 6 months after his exposure, it is strange to think how to this very day I cannot sleep a night without great terrors of the fire and this very night could not sleep to almost two in the morning through great terrors of the fire (quoted in Saigh & Bremner, 1999, p. 1). There has been remarkable consistency in the description of such posttrau-

Historical Conceptualizations

Sigmund Freud rebelled against the primary focus on organic explanations for psychopathology in vogue during that period. Because of his influence, psychological etiologies began to be proposed for understanding and treating psychopathology, in general, and posttraumatic reactions, in particular. Freud theorized that, because traumatic events overwhelm the psyche, traumatized individuals must engage extremely primitive defense mechanisms such as dissociation, repression, and denial. Catharsis and abreaction, involving high levels of emotional expression, were considered the necessary treatment for countering these primitive defenses (Freud, 1950). Other contemporaneous psychological conceptualizations of combat trauma included nostalgia (Civil War), battle fatigue combat exhaustion operational fatigue (World War I), and war traumatic neurosis (World War II) (Hyams et al., 1996). Although Freud stood strong against the winds of the medical and scientific culture pertaining to organic...

Anticipated Challenges And Achievements

Several factor-analytic studies since DSM-IV was published have raised questions about the nature and processes underlying PTSD (Foa, Riggs, & Gershuny, 1995 King, Leskin, King, & Weathers, 1998). These studies reveal that, contrary to the DSM-IV, there appear to be four, not three, clusters of PTSD symptoms. Symptoms of effortful avoidance and emotional numbing, included together in the DSM-IV, appear to have different properties, functions, and possible etiologies, according to these studies. Moreover, memory loss, a symptom included in the DSM-IV's avoidance numbing cluster, does not appear to be associated with the overall construct of PTSD or the symptom clusters. Interestingly, the most conclusive of these studies (King et al., 1998) does not support the notion that PTSD is an overarching, unitary disorder comprised of four symptom clusters. Rather, PTSD appears to be best conceptualized as a heterogeneous disorder with correlated, but separate, symptom manifestations....

Functional Analytic Clinical Assessment in Trauma Treatment

Assessment serves a variety of functions. In Chapter 3 of this volume, Pratt, Brief, and Keane provide a review of assessment procedures for the diagnosis of posttraumatic stress disorder (PTSD) as well as scales for assessing treatment outcome. One purpose of assigning a diagnostic label is its implication that a particular treatment will lead to a useful outcome, when properly applied to the appropriate person. If that useful outcome were always the case, then assessment for the purpose of diagnosis, along with an evaluation of treatment integrity, would be all that were necessary. Although much of this volume addresses how to treat patients who have experienced significant traumatic stressors, there is no treatment that is completely guaranteed to alleviate all of the symptoms a patient might report. This chapter focuses on the application of behavioral principles to assess areas of functioning that might need to be considered as treatment planning and implementation proceeds....

Functional Analytic Clinical Assessment The Purpose of Functional Analysis

The second heuristic to which to attend is to select controllable variables for study. Controllable here means to attend to a variable about which the therapist and the patient can do something. For example, the therapist cannot change the patient's age, but the therapist, could, in principle, change the patient's social repertoire in a way that increases his or her access to social reinforcement. This issue is particularly important in the treatment of PTSD when the patient would like more than anything to erase the traumatic stressor that seemingly caused all his or her problems in the first place. Of course, the event itself cannot be changed, but many of its consequences can be changed in the present.

Identifying Functional Variables That Interact With Treatments

One empirically supported treatment principle for PTSD is the use of cognitive therapy, whose techniques include identifying dysfunctional cognitions and gathering and evaluating evidence for and against those cognitions. Presumably, examining this evidence will lead the patient to a more realistic and functional set of beliefs and cognitions. If that intervention did not achieve the anticipated results and assuming that the treatment was delivered competently then we are left considering whether there are other important causal factors that could be identified by a functional analysis. In addition to the kinds of analyses already described, As a second example, in an exposure-based treatment that is producing poorer outcomes than might be expected, it is important to functionally analyze what environmental contingencies might be competing with therapy tasks and goals. If the therapist had constructed an in vivo desensitization hierarchy with the patient, and...

Thinking Outside The Black

Treatment itself can be thought of as adding to the person's history to change the impact of the traumatic event. Behavior theory long ago rejected any implied dualism between body and behavior. Behavior exists in a biological milieu. Behavior and biology cannot be separated and still retain sensible meaning. Therefore, one other source of behavioral variance to consider is how neurophysiological changes associated with traumatic experiences can alter the patient's interactions with the world. It is well beyond the scope of this chapter to try to resolve all of the interesting, though often conflicting, neurophysiological and neuroanatomical changes that are sometimes attributable to traumatic experiences, especially when experienced by the young. However, many functional and sometimes structural changes have been noted that may involve memory impairment changes in the hippocampus that could affect declarative memory, possible frontal lobe changes, and even changes in...

How To Evaluate The Functional Analysis

Because functional analyses are dynamic, often starting out incomplete and becoming more refined as data are gathered. As cautioned above, a functional relationship is limited in the domains it can influence and is limited in the time it is useful. Once one clinical problem is resolved, another may emerge that requires a whole new analysis. It is this idiographic procedure that can produce individualized treatment plans that can greatly supplement the evidenced-based treatment of individuals with PTSD.

Selection of Assessment Measures

Since the inclusion of PTSD in the diagnostic nomenclature of the American Psychiatric Association in 1980, excellent progress has been made in developing high-quality measures to assess trauma symptoms in adults (Keane & Barlow, 2002 Keane, Weathers, & Foa, 2000). The assessment and diagnosis of PTSD may require a range of different approaches, such as a clinician-administered structured diagnostic interview for PTSD and or related comorbidity, self-report psychological tests and questionnaires, and or psychophysiological measures. The clinician may also want to review medical records and check with multiple informants regarding the patient's behavior and experiences. We have referred to this approach as a multimethod assessment of PTSD (Keane, Fairbank, Caddell, Zimering, & Bender, 1995). When faced with a choice of measures, clinicians and researchers are encouraged Validity refers to the extent to which evidence exists to support the various inferences, interpretations,...

Types of Assessment Measures

Clinician-administered structured diagnostic interviews are considered extremely valuable tools for assessing PTSD symptomatology (Keane et al., 1995). Although it is standard practice in clinical research settings to employ structured diagnostic interviews, the use of these types of interviews in the clinical setting is less common, with perhaps the single exception of clinical forensic practice (Keane, 1995 Keane, Buckley, & Miller, 2003). In general, the infrequency of use may be due to time and cost burdens, as well as the need for specialized training to master the administration of many of these interviews. Nonetheless, it has been suggested that increased use of structured diagnostic interviews for PTsD in clinical settings may well improve diagnostic accuracy and aid in treatment planning (Litz & Weathers, 1994). several structured interviews are available that were developed for the assessment of PTsD either as modules of comprehensive diagnostic assessment tools or as...

Defining Abnormal Behavior

Similarly, if disorder is defined as a dysfunction in purely scientific terms, there are serious limitations. For example, a person in our culture who hears voices that others do not is assumed to have a disorder of cognitive processing. But, what about prophets, saints, and holy men who hear voices in other cultures or subcultures. Are they suffering from mental disorders The point is that some internal malfunctions do not cause harm to the individual nor do they cause harm to others. Thus, to consider the dysfunction a mental disorder it must be harmful to the individual or society. A hybrid definition where the behavior represents both a dysfunction (i.e., a scientific concept) and harm (i.e., a value concept) is necessary to label a condition as a mental disorder. Both components are necessary, and neither is sufficient alone. On occasions, labeling a person as disordered when the problem resides in the environment is a mistake. For example, the loss of loved ones will cause...

David S Riggs Shawn P Cahill Edna B

Posttraumatic stress disorder (PTSD) is an anxiety disorder that develops in some individuals following exposure to a traumatic event such as combat, sexual or physical assault, a serious accident, or the witnessing of someone being injured or killed (American Psychiatric Association, 1994). The classification of PTSD as an anxiety disorder reflects the longstanding recognition that anxious arousal plays a prominent role in people who experience pathological responses to trauma. However, research and theory into the nature of PTSD have documented that pathological reactions to trauma incorporate many emotions other than anxiety. Accordingly, in addition to reducing trauma-related anxiety and avoidance, treatments for PTSD are expected to modify other negative emotions such as guilt, shame, depression, and general anxiety. Anxiety has played an especially important role in the development of many treatment programs that target PTSD. These programs tend to focus on reducing or managing...

Facilitating PE Treatment

Patient (4) acknowledging the challenge presented by PE and (5) recognizing the patient's courage in electing to participate in the treatment program. More generally, it is important for the therapist to take a strong empathic, nonjudgmental stance throughout treatment to foster communication. The therapist should work actively to build the alliance with the patient. For example, the therapist should use the patient's own experience to illustrate concepts such as common reactions to trauma or in vivo exercises, and convey a strong commitment to apply PE in a way that takes into account the client's unique experience. It is also extremely important to foster a sense of collaboration between therapist and patient throughout treatment. The therapist and patient should work together to select the situations to be used in the in vivo exercises and which aspects of the trauma memory to be included during imaginal exposure. The essence of the collaboration is that the therapist makes...

Emotional Processing Theory of Natural Recovery

Although a necessary condition for the development of PTSD, exposure to trauma per se does not inevitably lead to chronic PTSD. Prospective studies of traumatized individuals indicate that PTSD symptoms, general anxiety, depression, and disruption in social functioning are common immediately after the traumatic event. Over the subsequent weeks and months, the majority of individuals recover naturally, with symptoms declining most rapidly during the 1- to 3-month period immediately following the trauma. This pattern of natural recovery has been documented for female rape victims (Atkeson, Calhoun, Resick, & Ellis, 1982 Calhoun, Atkeson, & Resick, 1982 Resick, Calhoun, Atkeson, & Ellis, 1981 Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992), male and female victims of nonsexual assault (Riggs, Rothbaum, Foa, 1995), and victims of motor vehicle accidents (Harvey & Bryant, 1998). Foa and Cahill (2001) suggested that, over time, trauma survivors encounter situations that include...

Modification of Fear Structures in PE

As noted above, Foa and Kozak (1986) proposed that, for emotional processing to occur, a fear network must be activated and information that is not compatible with it must be introduced and incorporated. Within the framework of PE, activating the fear network is accomplished through in vivo and imaginai exposure exercises. Successful activation of the trauma-related fear structure is indicated by fear responses such as physiological arousal, self-reports of distress, emotionally expressive behavior, and escape avoidance behavior. The introduction of new, incompatible information occurs in several ways. Foa andJaycox (1999) have summarized six different mechanisms or sources of information that are thought to be relevant to improvement in PTSD.

Studies of Exposure Therapy

A number of programs based on exposure therapy has been used to treat PTSD. Among the variations of exposure therapy, the PE protocol has been the most extensively studied and has been found to be highly effective. Like PE, some other exposure therapy programs include both imaginal confrontation with the traumatic memories and in vivo exposure to trauma reminders (e.g., Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998), however, some programs rely exclusively on imaginal exposure to the trauma memory (Bryant et al., 2003a Cloitre, Koenen, Cohen, & Han, 2002 Tarrier et al., 1999). Even among programs that include both imaginal and in vivo exposure, there are differences in the specific application of the techniques. For example, PE utilizes both components from the beginning of treatment in contrast, Marks et al. (1998) introduced imaginal exposure in the first half of the program and in vivo exposure in later sessions. Finally, exposure therapy programs differ in the extent...

Variations on a Theme Studies of Other Exposure Protocols

Lowed by four sessions of in vivo exposure) compared to EMDR and relaxation. All three groups showed significant improvement in PTSD symptoms at the end of treatment. The exposure therapy group was significantly more improved than the group that received relaxation training. In contrast, the EMDR group did not differ from either the relaxation group or the exposure therapy group. Power and colleagues (2002) utilized Marks et al.'s (1998) combined treatment protocol (imaginal and in vivo exposure plus CR), offering patients up to 10 sessions over 10 weeks of exposure therapy or EMDR or wait list. Both active treatments resulted in significant reductions in PTSD severity, anxiety, depression, and functional impairment, and both treatments were superior to the waiting-list condition, which showed very little change. Few differences were observed between the two active treatments, except that EMDR required, on average, fewer sessions (4.2 vs. 6.4) and achieved greater reduction in...

Gender Ethnicracial And Life Span Considerations

Cardiac contusion can occur at any age and in both sexes, although more males than females are involved in traumatic events. Anyone at high risk for traumatic injuries, such as children and young adults in the first 4 decades of life, is at high risk for myocardial contusion. Because their bones may be more brittle, elderly patients also have an increased risk traumatic injury to the sternum is less tolerated by the elderly as contrasted with younger patients. Ethnicity and race have no known effect on the risk of cardiac contusion.

Concerns About Exposure Therapy

Therapists often raise concerns that the emotional arousal experienced by trauma survivors undergoing exposure therapy may be extremely distressing and even damaging. Indeed, several clinical researchers have expressed reservations about the safety of exposure therapy in the treatment of at least some populations with PTSD (e.g., Cloitre et al., 2002 Kilpatrick & Best, 1984 Pitman et al., 1991). Two potential safety issues, in particular, have gained attention in the literature (1) exposure therapy may exacerbate the very PTSD symptoms that it is designed to ameliorate and (2) although PTSD symptoms may be alleviated, other psychological symptoms (e.g., drinking, depression, guilt) may worsen. For years, the primary evidence for the dangerousness of exposure therapy has been a paper by Pitman et al. (1991) that described six cases of combat veterans whose PTSD symptoms worsened after treatment by imaginal exposure. However, the study from which the case series was obtained did not...

Prolonged or Multiple Traumas

It is not unusual for PTSD patients to report multiple traumatic experiences. Others report repeated or prolonged traumas in which they experienced similar assaults on more than one occasion (e.g., multiple assaults at the hands of an intimate partner childhood sexual abuse). The presence of multiple or repeated traumas raises the question of which trauma should be the target for imaginal exposure. Often therapists ask, Where do we start and must we conduct imaginal exposure to all of the events The answer to the second question appears to be no. Our clinical experience indicates that the gains made in response to imaginal exposure and processing of the most distressing memory (or perhaps the two most distressing memories) generalizes such that the distress associated with memories of the other events lessens without direct exposure exercises. This finding is important because within a 10- to 12-session treatment program, only two or, at most, three memories can be submitted to...

Model I Intensive Initial Training of Therapists Plus Ongoing Expert Supervision

As described above, we recently completed a study (Foa et al., 2002a) in which we trained community-based clinicians to use PE to treat rape survivors with PTSD. In this 6-year study we trained therapists with master's degrees in social work or counseling, using a training model in which an initial workshop was followed with ongoing supervision provided by expert PE therapists. All of the community therapists had substantial experience in working with survivors of sexual assault, but none of them had prior training in CBT, nor had they any experience with conducting research or delivering manualized interventions. Indeed, some of them expressed reservations about the ethics of doing research with rape victims and were initially reluctant to use manualized treatments with their patients. Of note, they were not opposed to using exposure therapy with rape survivors and readily accepted the idea that confronting painful memories, images, and feelings promotes healing. In the first step of...

Model II Intensive Initial Training of Therapists Plus Local Supervision

An example of dissemination conducted using this model is a series of efforts made by clinicians at the CTSA over the last several years to train therapists in Israel to deliver PE. CTSA experts have delivered 3- to 5-day workshops on PE to clinicians in Israel whose work focuses on trauma-related distress and PTSD. A number of the clinicians who have attended these workshops have traveled to the United States for additional training (lasting 2-3 weeks) at the CTSA, focused on the observation of experts using PE and acquisition of experience in supervising therapists in the use of PE. Subsequently, supervision groups have formed in Israel led by one or more of the clinicians who received the additional training at the CTSA. The supervision groups meet regularly, viewing tapes and discussing patients' treatment plans and progress. Although we remain available for consultation to the supervisors on an as-needed basis, our involvement as consultants at this point has been very limited....

Amy E Street Patricia A Resick

The increased media attention on posttraumatic stress disorder (PTSD) in recent years has highlighted both the scientific advances in this area and remaining questions about the pathology and treatment of PTSD. Among psychotherapeutic interventions, several cognitive-behavioral strategies have demonstrated efficacy (e.g., van Etten & Taylor, 1998). Commonly used cognitive-behavioral therapy (CBT) protocols include, but are not limited to, cognitive processing therapy (CPT Resick & Schnicke, 1993), prolonged exposure (PE Foa, Rothbaum, Riggs, & Murdock, 1991b Foa et al., 1999a), and stress inoculation training (SIT Foa et al., 1991b, 1999a). However, the mechanisms of action in these treatments are not well understood. The relative contributions of cognitive versus behavioral components of treatment have only begun to be explored. Further, the heterogeneity of strategies included under the rubric of cognitive therapy often makes it difficult to evaluate the relative utility of...

Assessment Of Cognitions

The TABS is an 84-item measure that identifies disruption in several dimensions that impact interpersonal relationships, including Safety, Trust, Esteem, Intimacy, and Control. Similarly, the PBRS is a 55-item measure developed for use with sexual assault survivors to assess eight dimensions of Safety, Trust, Power, Esteem, Intimacy, Negative Rape Beliefs, Self-Blame, and Undoing (i.e., trying to deny or alter the event as a method of assimilation). Three subscales of the PBRS are predictive of intrusive symptoms of PTSD (Self-Blame, Undoing, and Safety), whereas four scales were predictive of avoidant symptoms of PTSD (Trust, Self-Blame, Undoing, Intimacy), and two scales were predictive of arousal symptoms (Power, Safety Mechanic & Resick, 1993). The WAS is a 32-item measure that evaluates eight categories of personal beliefs, including Benevolence of the World, Benevolence of People, Justice, Controllability of Life Events, Randomness of Life Events, Self-Worth, Self-Control,...

Theoretical Orientation

DBT is considered a principle-driven (as opposed to a protocol-driven psychotherapy) therefore, a thorough understanding of the theories upon which it is based is essential for the effective application of the treatment. This point is particularly relevant when considering novel applications of DBT, such as to the treatment of PTSD and related problems. There are three main theories that underlie the treatment the biosocial theory (of the etiology of BPD), behavioral theory, and the theory of dialectics.

Analysis of the Behavior in Context

One of the fundamental issues in functional understanding of clinical interventions is to appreciate the proper unit and level of analysis of a behavioral problem. In the case of PTSD it can be tempting to see the problem as residing in the relationship between the patient and the traumatic stressor. In fact, because there is considerable variability in how patients respond to stressors, we must infer that there are other factors that affect course and outcome. From a behavior analytic perspective it is important to appreciate that examining behavior in isolation misses the point. The only meaningful unit of analysis is the behavior in context. By context we mean that not only must the patient's responses to the characteristics of the stressor be considered, but they must be considered in light of the patient's history prior to the stressor, along with how the people, institutions, and agencies that are part of the patient's environment purposefully or inadvertently reinforce (or...

Mary Ann Cohen and David Chao

Have comorbid psychiatric disorders that are co-occurring and may be unrelated to HIV (such as schizophrenia or bipolar disorder). The complexity of AIDS psychiatric consultation is illustrated in an article (Freedman et al., 1994) with the title Depression, HIV Dementia, Delirium, Posttraumatic Stress Disorder (or All of the Above).''

Description Of Empirical Research

This review is useful for considering possible applications of DBT to PTSD and related problems. First, a number of the diagnoses and problems mentioned above frequently co-occur with PTSD, such as suicidal behavior, substance use disorders, and eating disorders. Therefore, DBT may be useful for the treatment of these coexisting problems, prior to the instigation of exposure-based treatments for PTSD. DBT has, in fact, been proposed as a first stage of treatment for individuals with PTSD, toward the goal of stabilization prior to exposure (Becker & Zayfert, 2001 Melia & Wagner, 2000). This suggestion is supported by both theory and research that emphasize the ability to effectively regulate emotions (i.e., not engage in dysfunctional behavior in the presence of emotional cues) as requisite for exposure to be effective (see Wagner, 2003). Further, given that a sizable portion of individuals with BPD meet criteria for PTSD as well (up to 50 in the samples used by Linehan), the...

Guidelines for Client Selection

A related consideration of particular relevance to the application of DBT to novel populations is the extent to which the client's presenting problems can be conceptualized according to theories upon which DBT is based. The existing studies seem to suggest that DBT is effective for clients whose problems can be conceptualized according to the biosocial theory as well as the behavioral theory (which emphasizes motivational factors and skills deficits in the maintenance of problem behavior). Because the problems of many clients with severe trauma histories or PTSD can be conceptualized this way (described further below), DBT may be effective for this population as well. DBT, as with many behavioral therapies, emphasizes fully orienting clients to the goals and expectations of therapy before it begins. Clients are not considered to be in DBT until they agree to the goals and expectations of the treatment therefore, clients who do not demonstrate a moderate degree of commitment are likely...

Robyn D Walser Steven C Hayes

Acceptance and commitment therapy (ACT Hayes, Strosahl, & Wilson, 1999) is a behaviorally based intervention designed to target and reduce experiential avoidance and cognitive entanglement while encouraging clients to make life-enhancing behavioral changes that are in accord with their personal values. Although ACT has been applied to a wide variety of problems, it is well suited to the treatment of trauma. Individuals who have been diagnosed with posttraumatic stress disorder (PTSD) are often disturbed by traumatic memories, nightmares, unwanted thoughts, and painful feelings. They are frequently working to avoid these experiences and the trauma-related situations or cues that elicit them. In addition to the symptoms of PTSD, the painful emotional experience and aftermath of trauma can often lead traumatized individuals to view themselves as damaged or broken in some important way. These difficult emotions and thoughts are associated with a variety of behavioral problems, from...

Avoidance Fusion and Pathology

Many of the problematic behaviors seen in PTSD may be the result of unhealthy avoidance strategies, fed by cognitive fusion. Steps taken to avoid experiential states may include directed thinking, rumination, and worry. These cognitive strategies are ways to distract oneself from current experience and the cognitive material associated with emotional content (Wells & Matthews, 1994). Worry and self-analysis seem to provide control over events but, in fact, have been shown to have minimal constructive benefit (Borkovec, Hazlett-Stevens, & Diaz, 1999) and may only serve to complicate psychological struggle. Numbing oneself to emotional responses or engaging in one type of emotional reaction as a way to avoid another (e.g., using anger to avoid hurt), and removing oneself from situations and personal interactions that elicit certain negative thoughts or emotions are all examples of avoidance maneuvers. A victim of trauma may spend large amounts of energy engaging in a number of...

Trauma History and Response to Trauma History

If the patient is willing to discuss the painful experiences, it is helpful to ask direct and closed-ended questions unless the patient proceeds to tell the story in his or her own words. The patient may, in fact, feel relieved to be able to talk about these secrets after many decades. Questions may include those about physical and emotional abuse as well as neglect. Asking about being a witness to physical or threatened violence on a repeated basis or seeing one parent trying to hurt or kill the other parent may be relieving to the patient who has not been able to tell anyone about it because of threats or fear of reprisals. Specific questions about sexual abuse should elicit information about unwanted touching, molesting, or fondling as well as penetration, intercourse, and rape. It is also important to determine the dates of the traumatic events wherever possible. Later trauma such as rape, life-threatening robbery, kidnapping, or the witnessing of trauma, including combat-related...

Trauma And Interpersonal Effects

Although the majority of people exposed to trauma appears to be resilient to the experience (Bonanno, 2004), that is not the case for survivors of childhood abuse because such abuse typically involves repeated trauma at the hands of a trusted caregiver. In fact, for women with symptoms of posttraumatic stress disorder (PTSD), the most common etiology is childhood sexual or physical abuse (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). When trauma involves childhood sexual abuse, the long-term effects may include interpersonal problems, such as marital disruption (Nelson, Wangsgaard, Yorgason, Kessler, & Carter-Vassol, 2002), sexual dysfunction (Tsai, Feldman-Summers, & Edgar, 1978 Merrill, Guimond, Thomsen, & Miller, 2003 Noll, Trickett, & Putnam, 2003), and issues with trust and intimacy (for reviews, see Beitchman et al., 1992). A history of childhood abuse is also believed to increase the severity of traumatic response to interpersonal violence experienced as...

The Causes Of The Clinical Effects Of Trauma

Before advocating that FAP can be an ideal treatment for complex PTSD, we first turn to a theory of trauma and its treatment implications. A parsimonious way to understand the complexity of trauma and its effects is to utilize the principles of operant and respondent conditioning. This learning account of PTSD (Hyer, 1994) is based on Mowrer's (1960) two-factor theory. Essentially, this theory contends that symptoms or problematic behavior come from two sources. First, as a result of pairing previously neutral stimuli with a highly aversive event, visceral, autonomic responses are now evoked by these previously neutral stimuli. A simple example might be a woman who was attacked by a dog and who now has aversive emotional responses to being near dogs, hearing dogs, or even anticipating the possibility of running into a dog. This woman's emotional responses to dogs and their related stimuli constitute the first set of problems. Then, because of respondent conditioning, this woman would...

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