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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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