Assessment and Treatment Planning for PTSD

Christopher Frueh, Anouk Grubaugh, Jon D. Elhai, Julian D. Ford

• Publisher: Wiley
• Year: 2012
• Print ISBN: 9781118122396
• eBook ISBN: 9781118238134
• Edition: 1
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

Evidence-based approaches to diagnosing and treating PTSD in an array of specific populations and settings

This timely, practical guide for busy professionals:

• Covers strategies for those working in specialized practice settings, such as primary care facilities, prisons, and hospitals for the severely mentally ill
• Offers guidelines for conducting forensic evaluations
• Provides information on malingering assessment
• Explores new frontiers in PTSD assessment, including neuroimaging and genetic testing
• Offers practical guidance on the assessment of most recognized comorbid conditions
• Discusses the roles of ethnicity, race, and culture in assessing and treating PTSD
• Offers assessment strategies for specific populations, including veterans, children, and the severely impaired

Chapter 1

Introduction and Overview

Posttraumatic stress disorder (PTSD) was officially introduced into the psychiatric nomenclature in 1980, with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) by the American Psychiatric Association (APA). Over the past 30 years, this disorder has changed the landscape of trauma and general stress studies, and it has contributed to the development of a wide range of sociopolitical, conceptual, and clinical issues and questions. The concept of posttraumatic reactions has been widely absorbed by the general public with regard to psychological adjustment after major traumatic events, as well as a wide range of other life stressors. Public awareness of PTSD has been furthered by extensive news coverage of recent national and international news events, including the 9/11 atrocities; the wars in Iraq and Afghanistan; terrorist attacks in London and Madrid; hurricanes, earthquakes, tsunamis, and other natural disasters; widely publicized cases of child sexual abuse among church officials and national sports heroes; and genocides in Africa and eastern Europe. Mainstream media publicity and films since the Vietnam War have also likely played a role in the layman’s understanding of PTSD. A now common portrayal of returning combat veterans is that of the psychologically impaired victim-hero, found in Hollywood movies too numerous to count, such as Taxi Driver (1976), Coming Home (1978), The Deer Hunter (1979), Born on the Fourth of July (1989), and In the Valley of Elah (2007).

Undoubtedly, research on every nook and corner of this disorder has abounded in the past few decades, providing patients and their families, clinicians, health care administrators, and policy makers with a vastly better understanding of posttraumatic reactions—from both a psychopathological and a resilient standpoint—than we had before. Despite this expansion of our knowledge, there remain numerous unanswered questions and controversies as to how clinicians should evaluate, define, and treat psychiatric symptoms in the aftermath of trauma events. Clinicians are left in their practices with questions that lack practical directions based on solid empirical evidence. A good deal of pseudoscience and poor science in the field of traumatology, as well as a proliferation of clinical myths, misconceptions, and fads about traumatic reactions, has further muddied the water for clinicians. Toward this end, we have produced a volume intended to help the dedicated evidence-based mental health practitioner with clinical assessment and treatment planning for people—patients, clients, consumers, however one wishes to term or define them—suffering from posttraumatic reactions.

This opening chapter begins with a historical perspective on posttraumatic reactions, segues into a brief review of important conceptual questions and issues with regard to the diagnosis of PTSD, and concludes with a general overview of evidence-based practice in mental health care and a discussion of why such practice is so important for people suffering posttraumatic reactions.

Historical and Societal Perspectives

The general notion that people are significantly affected, perhaps changed forever, by violent and horrific ordeals is not new. The postcombat reactions of warriors have been noted since ancient times throughout mythology and literature and in a variety of cultures (e.g., “Epic of Gilgamesh,” writings of Homer and Shakespeare). Since the 19th century, different terms have been used to describe posttraumatic reactions for a variety of dangerous and frightening experiences. Frequently, these terms provided clues as to how the etiology or nature of the symptoms was viewed at the time. In the years following the U.S. Civil War, it was noted that many veterans reported symptoms of chronic chest pain, as well as fatigue, shortness of breath, and heart palpitations—yet physical abnormalities to explain these symptoms were often not to be found. Physicians and caretakers were puzzled by the syndrome, which, while somewhat common, had no obvious explanation. The observed functional syndrome became known as soldier’s heart or Da Costa’s syndrome for the surgeon who noted it in a series of case reports (Barnes, 1870). During World War I, the term shell shock was used to refer to a constellation of symptoms believed to be a neurological disorder caused by the sound of explosions and bright flashes of light from bursting artillery shells on the Western Front. Combat fatigue was a term used during World War II, when it was believed that combat reactions were caused by exposure to extreme stress and fatigue. During the 1970s, victims of sexual assault were often identified as suffering from a “rape trauma syndrome” (Burgess & Holmstrom, 1974) or “battered woman syndrome” (Walker, 1977).

In organized psychiatry, the concept of a specific category of life events causing a psychiatric disorder was first formalized in 1952, with the first edition of the DSM. Gross stress reaction (GSR) was defined as a “transient situational personality disorder” that could occur when essentially “normal” individuals experienced severe physical demands or extreme emotional stress. GSR was soon dropped from psychiatry’s nosology in 1968, with the second edition of the DSM. Twelve years after the DSM-II’s publication, a more narrow class of events—that is, trauma—was linked as the causative agent for a new and specific constellation of symptoms, and posttraumatic stress disorder was formally defined and included in the psychiatric nosology.

The diagnosis of PTSD, added to the DSM in 1980, was largely the result of attempts to account for the challenging impairment presented by Vietnam veterans at the time of their homecoming (Satel & Frueh, 2009; Shephard, 2001, 2004; Wessely & Jones, 2004). In the immediate post-Vietnam era, compensation for significant functional impairment was difficult to obtain other than for observable physical injuries and access to Veterans Administration (VA) medical services were possible only via a “war-related” disorder (Wessely & Jones, 2004). Veterans’ advocates and antiwar activities were at the forefront of efforts to define and codify a “Vietnam syndrome,” a psychiatric response to war unique among Vietnam veterans. At about the same time in the 1970s, the feminist movement was politically strong and gaining momentum. They successfully began to expose the violence that was common against women, which led to the development of a “rape trauma syndrome” (Burgess & Holmstrom, 1974). These two activist groups soon joined forces to make a common cause with mental health clinicians and researchers. Together, they worked to influence the development of the new diagnostic addition to the DSM-III. Thus, along with medical and psychological science, the development of the clinical conceptualization of PTSD was heavily influenced by socioeconomic and political forces (Mezey & Robbins, 2001; Shephard, 2001). For a more in-depth discussion on the origins of PTSD, see Shephard (2001), Summerfield (2001), Jones and Wessely (2007), Rosen and Frueh (2010), and Satel and Frueh (2009).

A Unique Psychiatric Disorder

PTSD is unique from the vast majority of psychiatric disorders in the DSM in that it is the rare disorder to include an etiological explanation (trauma)—and one that is actually part of its diagnostic criteria (Criterion A). Otherwise, for the most part, the DSM takes an atheoretical approach to quantifying and classifying mental disorders. The fact that PTSD cannot be diagnosed without the occurrence of a Criterion A event not only makes PTSD distinct from other psychiatric diagnoses, but it also renders it unique in the general field of stress studies (Breslau & Davis, 1987). As Rosen, Frueh, Elhai, Grubaugh, and Ford (2010) noted:

Rather than all stressors creating an increased risk for a wide range of established conditions, there now was a distinct class of stressors that led to its own form of psychopathology. Thus, while any type of high stress could lead to increased risk of headaches, high blood pressure, or depression, only a Criterion A event such as combat, rape, or a life-threatening accident could lead to the distinct syndrome of PTSD. This assumption of a specific etiology, associated with a distinct clinical syndrome, provided the justification for a new field of “traumatology” to be carved out of general stress studies. (p. 7)

An Evolving Disorder

In the 30-plus years since its creation, the definition of PTSD has evolved steadily with each new revision of the DSM. Changes have been made to the definition of Criterion A, new symptoms have been added, and requirements regarding symptom onset and duration (Criterion E) have been modified.

In DSM-III (APA, 1980) the trauma criterion (Criterion A) was defined as: “Existence of a recognizable stressor that would evoke significant symptoms of distress in almost everyone” (p. 238). This stressor was described it as being outside the range of normal human experience. In DSM-IV (APA, 1994), Criterion A events are defined much more specifically:

The person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; (2) the person’s response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganized or agitated behavior. (pp. 427–428)

Moreover, by 1994, empirical research showed that traumatic events were actually quite common to the human experience, so that aspect of the DSM-III definition was dropped from the definition.

The number of possible PTSD symptoms expanded from 12 in DSM-III to 17 in DSM-IV and included the addition of avoidance behaviors. Also added was the caveat in Criterion E that duration of the disturbance had to exceed 1 month. This revision to Criterion E in DSM-IV was paired with a new (but related) diagnosis: acute stress disorder (ASD). Like PTSD, ASD requires a Criterion A traumatic event and includes symptom criteria very similar to PTSD (Criteria B through D). ASD cannot be diagnosed unless symptoms and associated impairment lasts at least 2 days (so as to exclude those with immediate peritraumatic reactions, which are very common) and may not last more than 4 weeks past exposure to the traumatic stressor. In this way, ASD serves as a diagnosis for those suffering extreme traumatic stress reactions that occur too soon after trauma exposure to be classified as PTSD.

PTSD’s defining criteria continue to be subject to much debate and discussion, and are likely to be revised in future editions of the DSM. We will return to further discussion of the future of PTSD in Chapter 12.

Important Conceptual Questions and Issues

Despite the proliferation of research on and expansion of clinical services for PTSD, much about the disorder remains misunderstood or unknown. In the sections that follow, we briefly introduce some of the important conceptual questions and issues regarding the diagnosis of PTSD that have implications for clinical assessment and treatment planning for people with significant traumatic event exposure.

Epidemiology of PTSD: Posttraumatic Morbidity Versus Resilience

There is now a widespread assumption on the part of many laypersons, journalists, and even clinicians that the majority of people who endure a traumatic experience, such as sexual assault, childhood abuse, a natural disaster, or wartime combat, will develop a psychiatric disorder as a direct result of the experience. However, the data actually tell a very different story. Most individuals will experience some short-term distress and may be affected in a variety of psychological ways. However, the majority of people who survive even the most horrific traumatic experiences do not develop PTSD or any other full-blown psychiatric disorder. That is, only a small minority of people will develop distress and functional impairment that rises to the level of a psychiatric disorder. Instead, long-term resilience is actually the norm rather than the exception for people after trauma (Bonanno, Westphal, & Mancini, 2011).

We now have a large body of epidemiological studies, conducted across a variety of populations, to inform our understanding of PTSD prevalence estimates (Breslau, Davis, Andreski, & Peterson, 1991; Davidson, Hughes, Blazer, & George, 1991; Dohrenwend et al., 2006; Norris, 1992; Smith et al., 2008). Data consistently show that exposure to potentially traumatic events (i.e., Criterion A) is quite common in the general population, with 60% to 80% of the population reporting exposure to various types of traumatic events (Breslau et al., 1991; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). PTSD rates (point-prevalence) are consistently found to be in the 6% to 9% range for both civilians and military veterans. For those who develop PTSD, about 50% will remit within 3 months without treatment (Galea et al., 2002; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). This is a robust finding that is specifically noted in DSM-IV. Individuals who are diagnosed with PTSD are at 3 times greater risk of meeting criteria again if exposed to a later traumatic stressor (Breslau, Peterson, & Schultz, 2008). In this way, PTSD can be a recurrent disorder after a first episode.

Psychiatric Comorbidity

Epidemiological studies also indicate that PTSD is not the only, or even the most likely, psychiatric reaction to follow trauma exposure. Fear, anxiety, sadness, anger, and guilt (among others) are common reactions to traumatic experiences. Other common reactions include physical or somatic complaints, such as insomnia, gastrointestinal symptoms, headaches, or sleep problems; social and relationship difficulties; and substance use, including alcohol and nicotine (Breslau et al., 1991; Bryant, 2010; Kessler et al., 1995). Major depression is probably the most common form of posttraumatic...

Table of contents

• Cover
• Contents
• Title
• Copyright
• Acknowledgments
• Chapter 1: Introduction and Overview
• Chapter 2: Using Evidence-Based Practices
• Chapter 3: Working With Trauma Survivors
• Chapter 4: Assessing PTSD
• Chapter 5: Assessing Comorbid Conditions
• Chapter 6: Considering Ethnicity, Race, and Culture
• Chapter 7: Conducting Forensic Evaluations
• Chapter 8: Working With Children and Adolescents
• Chapter 9: Assessing Children and Adolescents
• Chapter 10: Working With Veterans
• Chapter 11: Working With Special Populations and Settings
• Chapter 12: PTSD Treatments and Treatment Planning
• Chapter 13: Follow-Up With Evaluation and Support
• Chapter 14: Going Forward
• Author Index
• Subject Index