Trauma And Its Wake

Charles R. Figley, Charles R. Figley

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134843855
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Published in the year 1985, Trauma and its Wake is a valuable contribution to the field of Counseling and School Psychology.

SECTION

III

RECENT TREATMENT INNOVATIONS

CHAPTER

10

Post-trauma Stress Assessment and Treatment: Overview and Formulations

RAYMOND M. SCURFIELD

The author wishes to acknowledge the estimated 3.7 million men and women Vietnam theater veterans and their families, and the 574 dedicated, overworked and wonderful staff of the 136 Veterans Administration Vietnam-Era Veteran Counseling Centers (“Vet Centers”); Vet Centers have provided readjustment counseling services to over 200,000 Vietnam theater veterans and their families since 1979. The author does not purport to represent the views of the V.A.

An overview and formulation of the issues, assessment and treatment of post-traumatic stress disorder (PTSD) among survivors of various traumata is provided. There is discussion of such related areas as literature findings regarding PTSD etiology, assessment, and treatment; issues and misconceptions concerning trauma survivors; problems in assessment and validation of the PTSD diagnosis; critical factors to consider in assessment; interviewing dynamics in assessment and treatment; and treatment implications regarding acute, chronic, and delayed PTSD, to include discussion of five generic PTSD treatment principles and group and family treatment.

An abnormal reaction to an abnormal situation is normal behavior.

Viktor Frankl (1959)
Nazi concentration camp survivor

There are several prominent areas that must be discussed in order to provide a comprehensive overview of the assessment and treatment of post-traumatic stress. These areas include a review of the traumatic stress literature and formulation of central elements in the assessment and treatment of post-traumatic stress disorder (PTSD): 1) the critical etiological factors in the development of PTSD; 2) issues and misconceptions concerning trauma survivors; 3) problematic areas in assessment and validation of the PTSD diagnosis; 4) interviewing dynamics in the assessment process; 5) five generic PTSD treatment principles; 6) aspects of acute, and longer term PTSD treatment; and 7) peer group and family treatment.

BACKGROUND

There has been a prevalent belief that post-trauma psychological symptoms, particularly those which persist over time, are primarily due to 1) pre-morbid personality factors (e.g., factors or deficits existing prior to the trauma that “predisposed” persons to manifest psychological or somatic symptoms following the trauma), or 2) that claims for disability compensation and other forms of secondary gain were the major factors in prolonging acute stress reactions (Kalinowski, 1950). Such perspectives implied that “healthy” persons must have seemingly unlimited abilities to handle stress. Thus, as an example, a military veteran who presented significant and persistent symptoms following combat was considered to have an underlying neurotic personality (hence the terms “war neurosis” in World War I and “traumatic neurosis” in World War II [Figley, 1978; Goodwin, 1980]).

The recent publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association, 1980), acknowledged that almost anyone might develop psychiatric symptoms following exposure to an extremely stressful event. Particularly significant about the DSM-III classification of PTSD is the inclusion of the “chronic” (duration of symptoms at least six months or longer) and “delayed” (onset of symptoms no sooner than six months after the trauma) subtypes. PTSD criteria include: an identifiable stressor that is of such a magnitude that it would be expected to “evoke significant symptoms of distress in almost everyone,” a reexperiencing of the trauma (through flashbacks, intrusive thoughts, etc.), a numbing of responsiveness to or reduced involvement with the external world, and other specific symptoms (sleep disturbances, survivor guilt, hyperalertness, memory impairment and so forth) (APA, 1980, p. 236).

PTSD ETIOLOGICAL FACTORS

One set of findings in the literature concerns the relationship between pre-morbid personality factors and post-traumatic disorders. On the one hand, several studies of Vietnam veterans indicate a primary relationship between pre-military factors and the emergence of post-trauma symptoms (Baraga, Van Kampen, Watson, Czekala, & Kuhne, 1983; Borus, 1974; Helzer, Robins, Wish, & Hesselbrock, 1979; Panzarella, Mantell & Bridenbaugh, 1978; Robins, 1978; Robins, David & Goodman, 1974; Worthington, 1978). In contrast, however, studies of mental symptoms following head injury (Ader, 1945), a 12- to 16-year follow-up of concentration camp survivors (Strom, Refsum, Eitinger, Gronvik et al., 1962), a long-term study of 36 survivors of an off-shore oil explosion (Leopold & Dillon, 1963), a follow-up study of US Air Force prisoners of war (Ursano, 1981), a study of 43 Vietnam era veterans seeking mental health services at a medical center (Foy, Sipprelle, Rueger, & Carroll, 1984), a further analysis (Ransom, 1974) of a clinical sample of World War II air crews (Grinker, Willerman, Bradley & Fastovsky, 1946), a clinical examination of 303 concentration camp survivors (Hocking, 1970), a survey of 1,500 young men before and after military service (Card, 1983), a study of Vietnam veterans being treated for substance abuse (Penk, Robinowitz, Roberts, Patterson & Dolon, 1981) and studies of natural disaster victims (Melick, Logue & Frederick, 1982), all revealed little or no correlations between pre-trauma factors, the presence or severity of post-traumatic symptoms, and the apparent primacy of exposure to trauma as one of, if not the, critical etiological factor in the emergence of PTSD.

There also is evidence to suggest that stress symptoms following exposure to severe enough trauma persist over time (Dobbs and Wilson, 1960) and may in fact increase in severity (Archibald & Tuddenham, 1965; Chodoff, 1970; Leopold & Dillon, 1963; Strom et al, 1962; Ursano, Boydstun, & Wheatley, 1981).

The Vietnam war and its aftermath have led to an explosion of published reports describing PTSD among Vietnam veterans. Most reports suggest that there is a growing incidence of PTSD and that it is related to the intensity of combat exposure (DeFazio, Rustin & Diamond, 1975; Figley, 1978, 1979; Figley & Southerly, 1980; O’Neill & Fontaine, 1972; Schnaier, 1982; Ursano, 1981; Wilson, 1980b; Wilson & Krauss, in press); to the isolation and the lack of positive social supports upon returning home (Figley & Leventman, 1980; Keane & Fairbank, 1983; Wilson & Krauss, in press) and to pre-morbid factors. Wilson and Krauss report data that provide yet a different perspective—that pre-morbid behavioral tendencies were aggravated as a consequence of combat. Finally, further analysis of a national survey of Vietnam veterans (Egendorf, Kadushin, Laufer, Rothbart & Sloan, 1981) showed that while some pre-service behavior patterns contribute to some post-war adjustment problems, so do social characteristics such as race, and most importantly, there is a continuing significant influence of war experiences (Laufer, Frey-Wouters & Gallops, this volume).

Limitations of the Literature

Unfortunately, almost none of the research to date appears to adequately incorporate all of the following: scientifically rigorous research methodology addressing the full range of pre-trauma, trauma, and post-trauma factors, examination of both clinical and non-clinical populations, and psychologically sophisticated instrumentation. For example, a number of the studies that have suggested a primary relationship between pre-military factors and PTSD have inadequately (or not at all) measured the severity or other more refined aspects of the trauma. There are several instruments that measure levels of exposure to trauma (Egendorf et al., 1981; Figley, 1980; Foy et al., 1984; Keane, this volume; Horowitz, Wilner, & Alvarez, 1979; Wilson & Krauss, in press). However, there has been only limited psychometric refinement or calibration of such instruments across a range of populations. Finally, only two studies are prospective in nature, e.g., they include pre-trauma data that were collected prior to the trauma. Both of these studies indicate a primary relationship between factors about the trauma per se and PTSD (Card, 1983; Ursano, 1981).

Taken in its entirety, this author concludes that the literature to date seems to support a primary role of trauma in the etiology of PTSD. However, there are sufficient other findings to suggest that assessment of the interactional and cumulative effects among all three sets of factors (pre-trauma, trauma and post-trauma) are critical to a full understanding and assessment of PTSD.

VALIDITY OF THE DIAGNOSIS OF PTSD

Reliability and validity of the DSM-III (APA, 1980) criteria for PTSD across the range of clinical and non-clinical populations is sorely lacking. One examination of stress disorder symptoms among some of the sample in the Legacies of Vietnam study by Egendorf et al. (1981) and a comparative analysis with the DSM-III criteria for PTSD revealed a stress disorder syndrome that essentially was quite similar to the DSM-III criteria (Boulanger, Kadushin, Rindskopf, & Juliano, 1982). Several studies, however, offer some evidence to suggest additions to, or deletions from, the DSM-III, PTSD criteria (Atkinson, Sparr, Sheff, White & Fitzsimmons, 1984; Baraga et al., 1983; Hough, Gongla, Scurfield, Corker, Carr, & Escobar, 1984; Silver & Iacono, 1984; Wilson, Smith & Johnson, this volume). In addition, the DSM-III criteria do not appear to adequately discriminate between symptoms that are part of an expected or normal process and those of a disordered process (Smith, Parson & Haley, 1983). And so, while clinicians familiar with post-traumatic stress seem to be clear in their own minds about the PTSD diagnosis, there remains a lack of a rigorously tested, empirically based validation concerning just what constitutes PTSD (Figley, 1978), DSM-III notwithstanding.

METHODS TO DIAGNOSE PTSD

Currently, there is little or no empirical basis to justify the utilization of other methods to unequivocably validate a diagnosis of PTSD that has been obtained by an expert clinical examination. The findings of two recent studies show some promise that there may be a subscale of the Minnesota Multiphasic Personality Inventory (MMPI) that correctly classifies PTSD at 82% and 83% respectively (Foy et al., 1984; Keane, Malloy & Fairbank, in press; Keane, this volume). A third study found a different set of MMPI predictors (Roberts, Penk, Gearing, Robinowitz, et al., 1982). Problem checklist items reflective of anxiety-based disorders had over a 90% correct classification rate (Foy et al., 1984).

Two recently developed instruments have been designed to obtain DSM-III diagnoses, including PTSD: 1) the Diagnostic Interview Schedule (DIS) (Robins, 1981; Robins & Helzer, 1984) and 2) the Structured Clinical Interview for DSM-III (SCID) (Spitzer & Williams, 1983). However, to date there is only one pilot study on the accuracy of the DIS PTSD section (Russel & Willenbring, 1983). Preliminary findings in another study on a DIS-based PTSD scale indicate a .83 concordance with an expert clinical examination-derived PTSD diagnosis (Hough et al., 1984).

The development of a multimethod assessment of PTSD to include physiological measures (Malloy, Fairbank & Keane, 1983) at this point in time appears to be a desirable goal, though difficult to attain so far. Two recent studies report distinctive physiological responses among PTSD patients under controlled laboratory conditions (Blanchard, Kolb, Pallmeyer & Gerardi, 1983; Malloy et al., 1983).

In conclusion, it would appear that methods, other than the expert clinical examination, to validate a diagnosis of PTSD are in the developmental and pilot test stages, and serve a useful ancillary role to the clinician-derived diagnosis (Arnold, 1985a).

DISBELIEF CONCERNING “DELAYED STRESS” AND PTSD

Most Americans have been spared exposure to severe and repeated or protracted traumatic events. Thus, the course of post-trauma symptom development, which includes a “freezing of affect” and delay in symptom onset, is difficult to appreciate among the general public. There also is a persistent disbelief that “healthy” personalities can experience prolonged psychiatric difficulties following a traumatic event, in spite of studies and clinical experiences that suggest the contrary. Indeed, typical reactions to trauma and trauma survivors seem to be laced with an aversion to even a distant or brief contact with the horrors of trauma as might be experienced through intimate interaction with trauma survivors.

Moreover, psychoanalytic theories of personality development, which are the ruling ethos in mental health, minimize or deny the importance of events and developments that occur in adolescence or adulthood—except, perhaps, as they might exacerbate preexistent personality aspects. Humanistic and existentially oriented belief systems emphasize the present, the “now” ethos. Ironically, coming from an entirely different perspective, they may also have contributed to the lack of attention paid to the impact of adult trauma.

PROBLEMATIC AREAS IN THE DIAGNOSIS OF POST-TRAUMATIC STRESS DISORDERS

There is relatively little difficulty in making an accurate PTSD diagnosis when relatively “pure” trauma-specific PTSD is present. This is particularly likely to occur when the trauma is in the patient’s fairly recent past and/or when the patient and/or clinician can fairly readily perceive a link between the trauma and current symptoms. For example, a woman reports suffering violence-laden nightmares about being assaulted ever since being raped two months previously and there is no history of such nightmares prior to the rape. However, the trauma may have occurred long enough ago that it is not identified by patient or clinician as a, or the, source of current difficulties. For example, military veterans who entered Veterans Administration (or any) substance abuse programs in the 1970s routinely were not queried about the existence of combat-related trauma, nor was any attempt made to systematically explore the possible linkage of such trauma to the substance abuse (Figley, 1978). The veteran, in turn, was unlikely to attribute current substance abuse to military experiences per se.

Maladaptive Coping in Chronic and Delayed PTSD

The longer the PTSD goes untreated the more ingrained the maladaptive coping and denial patterns become. Such patterns can become entrenched to the point where they are an integral part of the presenting clinical picture. They may require specific treatment in and of themselves, along with or sequentially to treatment for PTSD. For example, paranoia, feelings of retaliatio...