| Traumatic
stress encompasses exposure to events or the witnessing
of events that are extreme and/or life threatening.
Traumatic exposure may be brief in duration (e.g.,
an automobile accident) or involve prolonged, repeated
exposure (e.g., sexual abuse). The former type has
been referred to as "Type I" trauma and
the latter form, as "Type II" trauma (Terr,
1991). In North America, four out of ten people
are exposed to at least one traumatic event in their
lifetime (Meichenbaum, 1994). Approximately, 25%
to 30% of individuals who witness a traumatic event
may develop chronic posttraumatic stress disorder
(PTSD) and other forms of mental disorders (e.g.,
depression) (Yehuda, Resnick, Kahana, & Giller,
1993). Approximately 50% of individuals who develop
PTSD continue to suffer from its effects decades
later without treatment (Meichenbaum, 1994). Knowledge
about traumatic stress- how it develops, how it
manifests, and how it affects the lives of those
who suffer with it- is the first step in its assessment
and, ultimately, its treatment.
History of Traumatic Stress
Traumatic exposure and its aftermath
are not new phenomena. Humans have experienced tragedies
and disaster throughout history. Evidence for post-traumatic
reactions date back as far as the Sixth century
B. C.; early documentation typically involved the
reactions of soldiers in combat (Holmes, 1985).
Beginning in the 17th century, anecdotal evidence
of trauma exposure and subsequent responses were
more frequently reported. In 1666, Samuel Pepys
wrote about individual's responses to the Great
Fire of London (Daly, 1983). It had been reported
that the author Charles Dickens suffered from numerous
traumatic symptoms after witnessing a tragic rail
accident outside of London (Trimble, 1981).
Traumatic stress responses have
been labeled in numerous ways over the years. Diagnostic
terms applied to symptoms have included Soldier's
Heart, Battle Fatigue, War Neurosis, Da Costa's
Syndrome, Tunnel Disease, Railway Spine Disorder,
Shell Shock, Gross Stress Reaction, Adjustment Reaction
of Adult Life, Transient Situational Disturbance,Traumatic
Neurosis, Post-Vietnam Syndrome, Rape Trauma Syndrome,
Child Abuse Syndrome, and Battered Wife Syndrome
(Everly, 1995; Meichenbaum, 1994). The Diagnostic
and Statistical Manual of Mental Disorders-Third
Edition (DSM-III) first recognized Posttraumatic
Stress Disorder (PTSD) as a distinct diagnostic
entity in 1980 (APA, 1980). It was categorized as
an anxiety disorder because of the presence of persistent
anxiety, hypervigilance, exaggerated startle response,
and phobic-like avoidance behaviors (Meichenbaum,
1994). This recognition of stress-related reactions
was a major step in the development of an empirical
literature base investigating traumatic stress.
In 1994, The Diagnostic and Statistical Manual
of Mental Disorders-Fourth Edition (DSM-IV)
was published and the current diagnostic criteria
reflect the findings of numerous empirical studies
and field trials (APA, 1994).
Types of Traumatic Events
Traumatic events are typically
unexpected and uncontrollable. They may overwhelm
an individual's sense of safety and security and
leave a person feeling vulnerable and insecure in
their environment. Events that are abrupt, often
lasting a few minutes and as long as a few hours
can be referred to as short-term or Type I traumatic
events (Terr, 1991). Included within this category
are natural and accidental disasters as well as
deliberately caused human-made disasters. Natural
disasters include events such as hurricanes,
floods, tornadoes, earthquakes, volcanic eruptions,
and avalanches. Accidental disasters may
include motor vehicle accidents (MVA), boat, train,
airplane accidents, fires, and explosions. Deliberately
caused human-made disasters (i.e., intentional
human design or IHD) involve bombings, rape, hostage
situations, assault and battery, robbery, and industrial
accidents.
Sustained and repeated traumatic
events (or Type II traumatic events) typically involve
chronic, repeated, and ongoing exposure. Examples
include natural and technological disasters
such as chronic illness, nuclear accidents, and
toxic spills. Events resulting from intentional
human design include combat, child sexual abuse,
battered syndrome (i.e., spousal abuse), being taken
as political prisoner or prisoner of war (POW),
and Holocaust victimization. It is important to
consider that research indicates that, despite the
heterogeneity of traumatic events, individuals who
directly or vicariously experience such events show
similar profiles of psychopathology including chronic
PTSD and commonly observed comorbid disorders such
as depression, generalized anxiety disorder, and
substance abuse (Solomon, Gerrity, & Muff, 1992).
Current Diagnostic Criteria
and Other Considerations
The DSM-IV stipulates that in order
for an individual to be diagnosed with posttraumatic
stress disorder, he or she must have experienced
or witnessed a life-threatening event and reacted
with intense fear, helplessness, or horror. The
traumatic event is persistently reexperienced (e.g.,
distressing recollections), there is persistent
avoidance of stimuli associated with the trauma,
and the victim experiences some form of hyperarousal
(e.g., exaggerated startle response). These symptoms
persist for more than one month and cause clinically
significant impairment in daily functioning. When
the disturbance lasts a minimum of two days and
as long as four weeks from the traumatic event,
Acute Stress Disorder may be a more accurate diagnosis.
It has been suggested that responses
to traumatic experience(s) can be divided into at
least four categories (see Meichenbaum for a complete
review, 1994). Emotional responses include shock,
terror, guilt, horror, irritability, anxiety, hostility,
and depression. Cognitive responses are reflected
in significant concentration impairment, confusion,
self-blame, intrusive thoughts about the traumatic
experience(s) (also referred to as flashbacks),
lowered self-efficacy, fears of losing control,
and fear of reoccurrence of the trauma. Biologically-based
responses involve sleep disturbance (i.e., insomnia),
nightmares, an exaggerated startle response, and
psychosomatic symptoms. Behavioral responses include
avoidance, social withdrawal, interpersonal stress
(decreased intimacy and lowered trust in others),
and substance abuse. The process through which the
individual has coped prior to the trauma is arrested;
consequently, a sense of helplessness is often maintained
(Foy, 1992).
Post-traumatic symptoms often co-occur
with other psychiatric conditions; this is referred
to as comorbidity. For instance, substance abuse
(especially, alcoholism), anxiety (e.g., panic disorder),
depression, eating disorders, dissociative disorders,
and personality disorders may all co-occur with
PTSD. With regard to specific populations, Matsakis
(1992) reported that between 40% to 60% of women
in treatment for bulimia, anorexia, and obesity
had described traumatic experiences at some point
in their life. Kilpatrick et al. (1989) reported
that, among crime victims with PTSD, 41% had sexual
dysfunction, 82% had depression, 27% had obsessive-compulsive
symptoms, and 18% had phobias. Sipprelle (1992)
reported that personality disorders were especially
widespread among Vietnam Veterans. Thus, it is important
to assess for comorbid disorders when seeing a patient
who presents with trauma-induced symptoms.
Assessment of Traumatic Stress
The clinician working with survivors
of traumatic stress and posttraumatic stress disorder
must consider the multifaceted nature of these disorders.
A multimodal approach which involves the collection
of information from a number of sources, using several
different methods over multiple contacts is highly
recommended (Meichenbaum, 1994). A comprehensive
clinical interview is a primary assessment tool
in the evaluation of traumatic stress. Careful questioning
during an interview allows the survivor to tell
his or her account of the event. Individuals need
the opportunity to talk about their experience in
a safe, non-judgmental setting. Survivors (and oftentimes,
their significant others) need to feel understood
and supported as they try to make sense of the traumatic
event. Questioning also facilitates a working alliance
with the person; the "connection" that
the person feels with the treating clinician is
often associated with continuation of treatment
and psychotherapy treatment outcome (Safran &
Segal, 1990; Wolfe, 1992). Questioning allows for
the gathering of details about the trauma, assessment
of current and past levels of functioning, and the
development of a treatment plan. Interviews with
family members and significant others may provide
further insight into the nature of the trauma and
presenting symptomatology. Commonly used structured
interviews include the Clinician Administered PTSD
scale (CAPS; Blake et al., 1990) and the Anxiety
Disorders Interview Schedule-IV (ADIS-IV; DiNardo,
Brown, & Barlow, 1994). A number of paper-and-pencil
assessment measures of PTSD have evolved over the
past few years as well. Some of the more popular
measures include the PTSD subscale of the Minnesota
Multiphasic Personality Inventory (MMPI; Keane,
Malloy, & Fairbank, 1984; Schlenger & Kulka,
1987 ), the Penn Inventory for PTSD (Hammarberg,
1992). Some screening instruments for anxiety and
depression that are also useful include the Beck
Anxiety Inventory (BAI; Beck, 1993) and Beck Depression
Inventory (BDI; see Beck, Rush, Shaw, & Emery,
1979). One performance-based measure that has been
used successfully with combat, rape, and accident
disaster patients is the Stroop Color Word Test
(McNally, English, & Lipke, 1993). As indicated
earlier, assessment for comorbid disorders must
be part of the evaluative process (see Meichenbaum,
1994 for a complete review of assessment measures).
Treatment of Traumatic Stress
Many techniques have been used
to treat survivors after exposure to traumatic events.
Presently, no one form of intervention has been
shown to be superior for the treatment of traumatic
stress and PTSD. Ochberg (1995) divides treatment
methods into four categories. Education is
the first method. This includes educating the survivor
(and their families) about trauma and its effects
on daily functioning. Cognitive, behavioral, and
physical aspects of the stress response are explored
with the individual. The clinician and patient may
share books and articles relevant to the treatment
of the traumatic symptoms. This process helps give
meaning to the symptoms that he or she experiences
and may ultimately facilitate a sense of control
over them.
The second category involves holistic
health. This includes physical activity, nutrition,
spirituality, and humor as they contribute to the
healing of the individual. The clinician functions
as both a teacher and a coach to his patient, offering
support and encouragement as the individual attempts
various ways to appropriately heal him or herself.
The third group of treatment techniques
includes methods to enhance social support
and social integration. Included within this
category are family therapy and group psychotherapy.
The former typically helps to improve communication
and cohesion between family members. Group treatment
allows individuals to reduce feelings of isolation,
share difficult feelings and perceptions regarding
the trauma, and learn more adaptive coping strategies.
Finally, there are clinical interventions
best described as therapy. The goal of most
forms of therapy is to help the individual work
through their grief, extinguish fear responses,
and improve the quality of the individual's life.
For example, cognitive-behavior therapy typically
relies on exposure strategies to reduce intrusive
memories, flashbacks, and nightmares related to
the traumatic experience. Exposure to fear-producing
stimuli and cognitions in a safe and supportive
environment, over time, often reduces the impact
of these stimuli on the individual's reactivity
(Foa & Kozak, 1986). Cognitive restructuring
strategies are also utilized to address the meaning
and, oftentimes, distortions in thought processes
that accompany traumatic exposure (e.g., "Life
is awful", "All people are cruel").
Problem-solving training (D'Zurilla, 1986) may help
the individual combat indecisiveness and perceptions
of helplessness. Other techniques include relaxation
training, and guided imagery-based interventions.
Pharmacological treatment of traumatic
stress and PTSD indicates that different medications
may affect the multi-faceted symptoms of PTSD. For
example, Clonidine has been shown to reduce hyperarousal
symptoms. Propranolol, Clonazepam, and Alprazolam
appear to regulate anxiety and panic symptoms. Fluoxetine
may reduce avoidance and explosiveness whereas re-experiencing
of traumatic symptoms and depression may be treated
with tricyclic antidepressants and selective serotonin
reuptake inhibitors. It is important to note that
pharmacotherapy as a sole source of intervention
is rarely sufficient to provide complete remission
of PTSD (Vargas & Davidson, 1993).
As indicated earlier, traumatic
stress and particularly, PTSD, are complex and multi-faceted
and consequently, a multimodal assessment is recommended.
It is suggested that effective treatment will involve
a number of the aforementioned techniques. Future
research needs to address the outcomes of combining
various treatment approaches and maintaining treatment
gains over time.
Conclusions
It has been stated that post-traumatic
stress may represent "one of the most severe
and incapacitating forms of human stress known"
(Everly, 1995, p. 7). Fortunately, traumatic stress
and its consequences continue to gain recognition
and investigation in the helping professions although,
clearly, more research needs to be done. For example,
motor-vehicle accidents (MVAs) are quite common
and often precipitate traumatic stress and PTSD,
yet there is a dearth of literature examining their
impact as well as the treatment of survivors of
motor vehicle accidents.
Recognition of trauma-related stress
is the first step in an individual's road to a healthier
life. Medical and mental health professionals are
in an ideal position to offer information, support,
and/or the appropriate referrals to victims of traumatic
stress. Treatment with a clinician knowledgeable
and experienced in working with anxiety and trauma-related
difficulties can be a crucial factor in helping
victims learn to cope and live life more fully.
References
American Psychiatric Association
(1980). Diagnostic and statistical manual of
mental disorders (3rd ed.). Washington, DC:
Author.
American Psychiatric Association
(1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC:
Author.
Beck, A.T., Rush, A.J., Shaw, B.F.,
Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford.
Beck, A. T. (1993). Beck Anxiety
Inventory. The Psychological Corporation.
Blake, D., Weathers, F., Nagy,
L., Kaloupek, D., Klauminzer, G., Charney, D., &
Keane, T.
(1990). Clinician Administered
PTSD Scale (CAPS). Boston: National Center for
Post-Traumatic Stress Disorder, Behavioral Science
Division, Boston VA.
Cummings, N., & Vanden Bos,
G.R. (1981). The twenty year Kaiser-Permanente experience
with psychotherapy and medical utilization. Health
Policy Quarterly, 1, 159-175.
Daly, R.J. (1983). Samuel Pepys
and posttraumatic stress disorder. British Journal
of Psychiatry, 143, 64-68.
DiNardo, P.A., Brown, T.A., &
Barlow, D.H. (1994). Anxiety Disorders Interview
Schedule for DSM-IV: Clinician's Manual. New
York: Graywind.
D'Zurilla, T.J. (1986). Problem
solving therapy: A social competence approach to
clinical intervention. New York: Springer.
Everly, G.S. (1995). Psychotraumatology.
In G.S. Everly & J.M. Lating (Eds.), Psychotraumatology:
Key papers and core concepts in post-traumatic stress
(pp. 9-26). New York: Plenum.
Foa, E.B., & Kozak, M.J. (1986).
Emotional processing of fear: Exposure to corrective
information. Psychological Bulletin, 99,
20-35.
Foy, D.W. (1992). Introduction
and description of the disorder. In D. W. Foy (Ed.),
Treating PTSD: Cognitive-Behavioral strategies
(pp 1-12). New York: Guilford.
Hammarberg, M. (1992). Penn Inventory
for posttraumatic stress disorder: Psychometric
properties. Psychological Assessment, 4,
67-76.
Holmes, R. (1985). Acts of war.
New York: Free Press.
Keane, T.M., Malloy, P.F., &
Fairbank, J.A. (1984). Empirical development of
an MMPI subscale for the assessment of combat-related
post-traumatic stress disorder. Journal of Consulting
and Clinical Psychology, 52, 888-891.
Kilpatrick, D. G., Saunders, B.E.,
Amick-McMullen, A., Best, C.L., Veronen, L.J., &
Resnick, H.S. (1989). Victim and crime factors associated
with the development of crime-related posttraumatic
stress disorder. Behavior Therapy, 20,
199-214.
Matsakis, A. (1992). I can't
get over it: A handbook for trauma survivors.
Oakland, CA: New Harbinger Publications.
McNally, R.J., English, G.E., Lipke,
H.J. (1993). Assessment of intrusive cognition in
PTSD: Use of the modified Stroop paradigm. Journal
of Traumatic Stress, 6, 33-42.
Meichenbaum, D. (1994). A clinical
handbook/practical therapist manual for assessing
and treating adults with post-traumatic stress disorder.
Ontario, Canada: Institute Press.
Ochberg, F.M. (1995). Post-traumatic
therapy. In G.S. Everly & J.M. Lating (Eds.),
Psychotraumatology: Key papers and core concepts
in post-traumatic stress (pp. 245-264). New
York: Plenum.
Safran, J.D., & Segal, Z.V.
(1990). Interpersonal process in cognitive therapy.
New York: Basic Books.
Schlenger, W.E., & Kulka, R.A.
(1987). Performance of the Keane-Fairbank MMPI scale
and other self-report measures in identifying post-traumatic
stress disorder. Paper presented at the 95th annual
meeting of the American Psychological Association,
New York.
Sipprelle, R.C. (1992). A vet center
experience: Multievent trauma, delayed treatment
type. In D.W. Foy (Ed.), Treating PTSD: Cognitive-Behavioral
strategies (pp 13-38). New York: Guilford.
Solomon, S., Gerrity, E.T., &
Muff, A.M. (1992). Efficacy of treatments for posttraumatic
stress disorder: An empirical review. Journal
of the American Medical Association, 268,
633-638.
Terr, L. (1991). Childhood trauma:
An outline and overview. American Journal of
Psychiatry, 148, 10-20.
Trimble, M.R. (1981). Post-traumatic
neurosis. Chicester: Wiley.
Vargas, M.A., & Davidson, J.
(1993). Post-traumatic stress disorder. Psychopharmacology,
16, 737-748.
Wolfe, B.E. (1992). Integrative
psychotherapy of the anxiety disorders. In J.C.
Norcross & M.R. Goldfried (Eds.), Handbook
of Psychotherapy Integration. (pp 373-401).
New York: Basic Books.
Yehuda, R., Resnick, H., Kahana,
J., & Giller, E. (1993). Long-lasting hormonal
alterations to extreme stress in humans: Normative
or maladaptive? Psychosomatic Medicine,
55, 287-297.
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of Experts in Traumatic Stress, Inc.
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