An Outline for the Identification and Treatment of Post Traumatic Stress Disorder
by M. Allan Cooperstein, PhD, DABFE, DABFM, DABPS, DAPA
http://members.tripod.com/allanpsych/
Originally published as Cooperstein, M. A. (January, 1999). Multidimensional Diagnosis and Causality: Identifying and Treating Posttraumatic Stress Disorder. American Psychotherapy Association Newsletter, 2(5), 3,6. Reprinted with permission from the author.
Psychotherapy begins with diagnosis, a process of identifying or determining the
nature and cause of a disease or injury through a critical analysis of a patient’s
history, an examination, and a review of empirical data. One of the most vexing issues
to be encountered in psychology is the identification—for clinical and forensic purposes—of
Posttraumatic Stress Disorder (PTSD). The Diagnostic and Statistical Manual of
Mental Disorders (1994) lists PTSD (309.81) under anxiety disorders, stating
that it may result from direct or indirect exposure to trauma. Its essential features
include intrusive and avoidance symptoms, and symptoms of hyperarousal,
for greater than 1 month and causing clinically significant distress or impairment
in important life areas. Indirect traumata may include observing the serious injury
or death of another person through violence, accident, war, or disaster or the chance
encountering of a corpse or body parts. Although Adjustment Disorder and PTSD both
require a psychosocial stressor, PTSD is identified by an extreme stressor and specific
symptoms, while Adjustment Disorder may be triggered by a stressor of any severity
and can involve a wide range of symptoms.
Forensic experts can assess emotional damage--including PTSD--claimed by the patient
or family within the context of life histories, including preexisting mental conditions
and prior experiences that make a patient vulnerable to trauma. They can also report
on the probability of faking, malingering, or exaggerating symptoms, assessments
of this type having value in establishing treatment plans/goals and in helping a
jury evaluate the patient’s credibility and damage.
Consequently, to appropriately and comprehensively assess PTSD we must examine
the nature and degree of trauma, the trauma history, the pretraumatic state (including
chronic strains, negative life experiences in the year before the trauma, health
problems over the preceding ten years, recent life events, and personality traits
and disorders), the immediate social surround, dynamics of the traumatic episode,
the posttraumatic state, social supports, and an altered worldview and belief systems.
Although an ever-growing corpus of literature and research information on PTSD
is extant, the goal of this article is to provide a brief, introductory overview
of the syndrome, its antecedents and precipitants, components of the experience and
treatment implications. Additional writings will examine each aspect in greater depth.
The Contexts of Trauma: Holistic Appraisal of the PTSD Syndrome
At least 7 factors have been found to be associated with PTSD as antecedents,
precipitants, or collateral events and/or features of PTSD.
- Pre-existing traumas. These have a cumulative or sensitizing effect upon
the ease of acquisition of later trauma (Blanchard & Hickling, 1997; Brewin,
Dalgleish & Joseph, 1996; McKenzie & Wright, 1996; Resnick, Yehuda &
Foy,1995).
- The pretraumatic state, the immediate social environment, the nature
of the trauma, the dynamics of the traumatic episode, and the nature
of the posttraumatic state which contribute to the stability of the disorder
(Woolston, 1988).
- Recent life events, chronic strains, and social supports (Ullman &
Siegel, 1994). Risk of increased posttraumatic stress (PTS) symptoms following a
traumatic event was associated with other life events, sexual assault, and household
strain. The level of PTS varied according to the trauma after adjusting for demographics.
Women and younger adults reported more PTS than other subjects.
- Negative life events during the year before the trauma, health problems during
the previous ten years, and a personality trait characterized by high emotional
reactivity (Tjemsland, Soreide, & Malt, 1998).
- Personality disorders. These may occur in 5 to 15 percent of the population.
Patients with personality disorder have not only a maladaptive response to stress
but elicit dysfunctional responses by a pervasive pattern of interpersonal stress
(Adams, 1997).
- Worldview: After trauma, one’s worldview (in German, Weltanschauung)
may alter. This is the general perspective used to perceive and interpret reality,
the existential beliefs supporting one’s existence. Perceptions of vulnerability
are heightened and self-view are significantly diminished for trauma victims, with
similar results across different types of trauma (Gluhoski & Wortman, 1996).
- The degree of trauma: There is a correlation between the severity of PTSD
and the presence of other disorders, including depression, substance abuse disorders,
adjustment disorders, psychosomatic disorders, and antisocial behavior (Rundell,
Ursano, Holloway, & Silberman, 1989).
Asking Mind, Asking Body: Incorporating Psychophysiological Assessment
Blanchard, Kolb, Pallmeyer, and Gerardi (1982) found that psychophysiological comparisons between male Vietnam veterans suffering from PTSD and nonveteran controls resulted in the two groups responding differently to combat reminders in heart rate (HR), systolic blood pressure, and forehead electromyography (EMG). HR responses led to correct classification of 95.5 percent of the combined sample. Similarly, in a replication study of physiological measures of injured motor vehicle accident
victims and non-injured controls, Blanchard, Hickling, Buckley, Taylor, Vollmer, and Loos (1996) found HR useful in distinguishing MVA victims with PTSD from those with subsyndromal PTSD and non-PTSD. The initial psychophysiological assessment results predicted 1-year follow-up clinical status for the majority of individuals who initially met criteria for PTSD.
Wickramasekera (1998) defines 3 risk factors associated with PTSD symptom intensity.
These are high hypnotic ability (high dissociation), low hypnotic ability (low dissociation),
and a high Marlowe-Crowne score (Crowne & Marlowe, 1960). The latter measures
culturally acceptable statements that are probably untrue of most people and undesirable
statements. These measures may produce incongruent responses between psychologi cal
measures (e.g. no perception or memory of negative emotions) and physiological (e.g.
sympathetic activation, high skin conductance, high heart rate, high blood pressure)
measures of threat perception. These risk factors reduce or block negative emotions
from conscious awareness but not from behavior (e.g. violence, avoidance, substance
abuse) or physiology (e.g. migraines, autonomic nervous system dysregulation, musculoskeletal
pain).
From the above, the usefulness of psychophysiological measures may be adduced as
a valuable supplement to PTSD assessment.
Dissociation and Hypnosis
Dissociation is described as "a disruption in the usually integrated functions
of consciousness, memory, identity, or perception of the environment. The disturbance
may be sudden or gradual, transient or chronic" (DSM IV, 1994). Posttraumatic
Stress Disorder (PTSD) may be conceptualized as part of a dissociative spectrum in
which recall/re-experiencing of the trauma (flashbacks) alternates with numbing (detachment
or dissociation), and avoidance (Turkus, 1992; also see Briere, Evan, Runtz, &
Wall, 1988; Carlson & Rosser-Hogan, 1991; Goodwin & Reynolds, 1987; Jaschke
& Spiegel, 1992; Kuch & Cox, 1992; Mellman, Randolph, Brawman-Mintzer, Flores,
& Milanes,1992; Roszell, McFall, & Malas, 1991; Shalev, Schreiber, &
Galai, 1993; Southwick, Yehuda, & Giller, 1993).
As Wickramasekera (1998) addressed hypnotizability, Spiegel, Hunt, and Dondershine
(1988) examined this trait in veterans with PTSD contrasted with a normal control
group and four patient samples. The results demonstrated that PTSD patients show
significantly higher hypnotizability scores than patients with schizophrenia, major
depression, bipolar disorder-depressed, dysthymic disorder, generalized anxiety disorder
and the controls. This supports the hypothesis that dissociation effects may are
used as defenses during and after traumatic experiences.
Bremner and Brett (1997) examined dissociation in premilitary, combat-related
and postmilitary traumas and the presence of long-term psychopathology in Vietnam
combat veterans with and without PTSD. Most interesting was the finding that PTSD
patients reported higher levels of dissociative states at the time of combat-related
traumatic events than non-PTSD patients. These higher levels of dissociative
states persisted in PTSD patients as higher levels of dissociation in response to
postmilitary traumatic events. The dissociative responses to combat trauma were linked
with higher, long-term dissociative symptoms as measured by the Dissociative Experience
Scale and an increased number of "flashbacks" since the time of the war.
The findings are congruent with earlier concepts that traumatic dissociation may
be a sign of long-term psychopathology.
Treatment Implications
Contrary to the symptom-specific expectations of insurance reviewers, current
research demands flexibility in the diagnoses and treatment of PTSD. In some instances
(see Foa, Hearst-Ikeda, & Perry, 1995), brief cognitive–behavioral program undertaken
shortly after assault reduce the re-experiencing of severe arousal symptoms as well
as depression. However, a history of physical abuse in childhood has been strongly
correlated with dissociative symptoms later in life as well as combat experiences
in veterans (Spiegel, &. Cardena, 1990). As dissociative symptoms during and
soon after traumatic experience predict later PTSD, brief, symptom-focused treatment
may not always be applicable.
Hypnotic procedures may be helpful because the population has been shown to be
highly hypnotizable. Hypnosis provides regulated access to painful memories that
may otherwise be blocked from awareness. In treating PTSD victims, dissociated traumatic
memories are connected with a positive restructuring of involved memories, a cognitive
reorientation. Accordingly, patients are helped to confront and manage traumatic
experiences by inserting them into a new context meaning or "worldview."
Feelings of helplessness are endorsed while experiences are interlaced with restructured
memories, emphasizing positive efforts at self-protection, affection with the living
and those who may have died, or the capacity to control events and the environment
at other times.
Although medication use shows a modest, clinically meaningful effect on PTSD,
in their literature review on the effectiveness of PTSD treatments, Solomon, Gerrity,
and Muff (1992) found more robust effects for behavioral techniques involving direct
therapeutic exposure in reducing PTSD intrusive symptoms. There is a caveat, however,
in that complications were reported from the use of these techniques in patients
with collateral psychiatric disorders. Cognitive therapy, psychodynamic therapy,
and hypnosis may also hold promise, but further research is needed.
Psychodynamic psychotherapy focuses on helping the patient examine their reactions
to the physical or emotional personal violations of the traumatic event(s). The goal
is to increase awareness of intrapersonal conflicts and their resolution. The patient
is guided towards developing increased self-esteem, self-control, and a regenerated
sense of personal integrity and self-confidence.
Group therapy may help PTSD patients develop a reference group and a sense of
community, reacquiring the capacity to relate to others in a controlled, health-inducing
manner and setting.
Most PTSD treatment is outpatient. When symptoms make it impossible to function or
lead to other symptoms (e.g., alcohol or drug problems) inpatient treatment may become
necessary.
Summary
PTSD is a diagnostically complex phenomenon requiring a multidimensional evaluation
including clinical interviewing, background history, adequate testing and test interpretation,
and psychophysiological assessment. These are imperative for diagnosis, treatment
and competent testimony (Levit, 1986). In my practice, interviewing, psychometric
testing, malingering/exaggerating measures, and physiological responses to positive,
negative and neutral stimuli are blended, similar to Scrignar’s (1988) biopsychosocial
model of PTSD, to include Environment, Encephalic Events, and Endogenous Events.
Effective psychological and pharmacological treatments are available for PTSD.
Medications may be used as a complement to psychotherapy to help sleeplessness and
hyperarousal. Psychotherapy restores the patient’s necessary sense of control while
decreasing the impact of past events over present experience. The sooner a patient
is diagnosed and treated, the more likely s/he is to recover from trauma. A sense
of safety and control in the patients’ lives must be re-established to help them
feel effective and secure enough to embrace the feared reality of the events that
transpired.
Social and familial support may be critical. Time must be permitted for grief
and mourning, while communicating about events and receiving support for feelings
of guilt, anger, self-blame, and depression. A treatment plan must be developed with
the patient to help establish what is needed to restore a sense of confidence, control
and predictability to life.
Forensic proof of the existence of PTSD requires that many of the needs and conditions
cited here are met. Even when presented with solid, empirical evidence of PTSD, adversaries
will often attempt to deny its existence or, as I have seen lately, attempt to transport
responsibility for present distress onto earlier events or injuries. As forensic
specialists, our primary, professional responsibilities are to the patient. However,
in serving the patient, we may also meet the needs of the legal system through responsible,
detailed, and thorough documentation of diagnosis and treatment supported by research.
References
Adams, D. B. (1997). Recovery from orthopaedic trauma: Psychodynamics and psychopathology:
Conclusion & implications. Psychotherapy Bulletin, 32(2), 131-136.
American Psychiatric Association. (1994). Diagnostic and statistical manual
of mental disorders (4th ed.) Washington, DC: Author.
Blanchard, E. B. & Hickling, E. J. (1997). After the crash: Assessment
and treatment of motor vehicle accident survivors. Washington, DC: American Psychological
Association.
Blanchard, E. B., Hickling, E. J., Buckley, T. C., Taylor, A. E., Vollmer, A..,
& Loos, W.R. (1996). Psychophysiology of posttraumatic stress disorder related
to motor vehicle accidents: Replication and extension. Journal of Consulting &
Clinical Psychology, 64,
742-751.
Blanchard, E. B., Kolb, L. C., Pallmeyer, T. P., & Gerardi, R. (1982). A psychophysiological
study of post traumatic stress disorder in Vietnam veterans. Psychiatric Quarterly,
54, 220-229.
Bremner, J. D., & Brett, E. (1997). Trauma-Related Dissociative States and
Long-Term Psychopathology in Posttraumatic Stress Disorder. Journal of Traumatic
Stress, 10(1),
37-49.
Briere, J., Evan, D., Runtz, M., & Wall, T. (1988). Symptomatology in men
who were molested as children. American Journal of Orthopsychiatry, 58, 457-461.
Brewin, C. R., Dalgleish, & Joseph, S. (1996). A dual representation theory
of posttraumatic
stress disorder. Psychological Review, 103(4), 670-686.
Carlson, E. B. & Rosser-Hogan, R. (1991). Trauma experiences, posttraumatic
stress,
dissociation, and depression in Cambodian refugees. American Journal of Psychiatry,
148, 1548-1551.
Crowne, D. P. & Marlowe, D. (1964). The approval motive. Westport,
CT: Greenwood
Press.
Foa, E. B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief
cognitive–behavioral program for the prevention of chronic PTSD in recent assault
victims. Journal of Consulting and Clinical Psychology, 63, 948-955.
Goodwin, J., & Reynolds, M. (1987). A post-traumatic reinterpretation of a
classic case of
multiple personality disorder. Hillside Journal of Clinical Psychiatry, 9,
89-99.
Gluhoski, V. L., & Wortman, C. B. (1996). The impact of trauma on worldviews.
Journal of
Social & Clinical Psychology, 15(4), 417-429.
Jaschke, V. A., & Spiegel, D. (1992). A case of probable dissociative disorder.
Bulletin of the
Menninger Clinic, 56, 246-260.
Kuch, K., & Cox, B. J. (1992). Symptoms of PTSD in 124 survivors of the holocaust.
American Journal of Psychiatry ,149, 337-340.
Levit, H. I. (1986). Soft tissue injury cases: Guidelines for the forensic psychologist.
American Journal of Forensic Psychology, 4(2), 8-15.
McKenzie, C. D., & Wright, L. S. (1996). Delayed posttraumatic stress disorder
from infancy: The two trauma mechanism. Amsterdam, The Netherlands: Harwood Academic
Publishers.
Mellman, T.A., Randolph, C. A., Brawman-Mintzer, O., Flores, L. P., & Milanes,
F. J. (1992). Phenomenology and course of psychiatric disorders associated with combat-related
posttraumatic stress disorder. American Journal of Psychiatry, 149, 1568-1574.
Resnick, H., Yehuda, R., Pitman, R., & Foy, D. (1995). Effect of previous
trauma on acute
plasma cortisol level following rape. American Journal of Psychiatry, 152(11),
1675-
1677.
Roszell, D. K., McFall, M. E., & Malas, K. L. (1991). Frequency of symptoms
and concurrent psychiatric disorder in Vietnam veterans with chronic PTSD. Hospital
Community
Psychiatry, 42, 293-296.
Rundell, J. R., Ursano, R. J., Holloway, H. C., & Silberman, E. K. (1989).
Psychiatric responses to trauma. Hospital & Community Psychiatry, 40(1),
68-74.
Scrignar, C. B. (1988). Post-Traumatic Stress Disorder: Diagnosis, Treatment
and Legal Issues, (2nd ed.). New Orleans: Bruno Press.
Shalev, A. Y., Schreiber S., & Galai, T. (1993). Early psychological responses
to traumatic
injury. Journal of Traumatic Stress, 6, 441-450.
Solomon, S. D., Gerrity, E. T., & Muff, A. M. (1992). Efficacy of treatments
for posttraumatic stress disorder. An empirical review. Journal of the American
Medical Association, 268(5), 633-638.
Southwick, S. M., Yehuda, R., & Giller, E. L. (1993). Personality disorders
in treatment seeking combat veterans with posttraumatic stress disorder. American
Journal of Psychiatry,
150, 1020-1023.
Spiegel, D., &. Cardena, E., (1990). New uses of hypnosis in the treatment
of posttraumatic
stress disorder. Journal of Clinical Psychiatry, 51(Supplement), 39-43.
Spiegel, D., Hunt, T., & Dondershine, H. E. (1988). Dissociation and hypnotizability
in
posttraumatic stress disorder. American Journal of Psychiatry, 145(3), 301-305.
Tjemsland, L., Soreide, J. A., & Malt, U. F. (1998). Posttraumatic distress
symptoms in operable breast cancer III: Status one year after surgery. Breast
Cancer Research Treatment,
47(2), 141-151.
Turkus, J. A. (1992,May/June). The spectrum of dissociative disorders: An overview
of
diagnosis and treatment. Moving Forward. Arlington, VA: P.O. Box 4426, 22204.
Ullman, S. E., & Siegel, J. M. (1994). Predictors of exposure to traumatic
events and
posttraumatic stress sequelae. Journal of Community Psychology, 22(4), 328-338.
Wickramasekera, I. (1998, Winter). Secrets kept from the mind, but not the body
and behavior. The Independent Practitioner, 18(1), 38-42.
Woolston, J. L. (1988). Theoretical considerations of the adjustment disorders.
Journal of the
American Academy of Child & Adolescent Psychiatry, 27(3), 280-287.
Notice of Copyright & Terms Of Redistribution
Copyright © 1999 M. Allan Cooperstein, PhD. All rights reserved.
No portion of this article may be reproduced without the express written permission
of the copyright holder.
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