| 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.
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©1996 by The
American Academy of Experts in Traumatic Stress,
Inc.
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