Post Traumatic Stress Theory

Research and Application

John Harvey, Brian Pauwels, John Harvey, Brian Pauwels

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135057732
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

Few phenomena are as widely experienced across different individuals, cultures, and contexts as that of traumatic stress. Whether as victims, perpetrators, supporters or simply observers, most people can identify to some extent with the psychological and physical consequences produced by traumatic events. This text examines the nature of traumatic stress, the contexts in which it occurs, and the needs and coping strategies of its survivors. Topics include the survivors of rape, soldiers of war, and the nature of coping with loss or trauma in old age. Furthermore, the roles of culture, social support, and more formal organizations in the ongoing process of overcoming trauma are explored as the text details the nature of traumatic experiences, the needs of survivors, and the challenges faced by those who wish to support and help those survivors.

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PART I
POST-TRAUMATIC STRESS: CONTEXTS AND CONSEQUENCES

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As mentioned in the introduction to this volume, the contexts in which traumatic events occur and can be studied are numerous. The specific nature of a given traumatic event can raise unique challenges for the victims who endure the event, the scholars who attempt to understand the event, and the practitioners who assist in the event's aftermath. Traumatic events vary on dimensions beyond the physical stressors that initially produce discomfort or disability. For example, they also differ in the extent to which cultural contexts contribute to that initial stressor. They vary in terms of the immediate and long-term consequences of the event, both for the victims and for those close to them. Finally, the nature of the trauma often dictates both the opportunities and obstacles faced by researchers and practitioners who seek to understand or intervene after the event occurs. The following chapters illustrate this diversity by describing a number of different contexts in which trauma can occur and the particular consequences that follow from those contexts.

CHAPTER ONE

LOSS OF TRUST: CORRELATES OF THE COMORBIDITY OF PTSD AND SEVERE MENTAL ILLNESS

CATHALEENE MAClAS and ROBERT YOUNG

Research Unit, Fountain House, Inc., New York, New York, USA

PAUL BARREIRA

Massachusetts Department of Mental Health, Boston, Massachusetts, USA

The prevalence of post-traumatic stress disorder (PTSD) in the general population of the United States is a topic of speculation, with estimates ranging from 0.4% to 9% (Breslau, Davis, Andreski, & Peterson, 1991; Helzer, Robins, & McEvoy, 1987; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Likewise, estimates of the prevalence of PTSD within the population of persons with serious mental illness have varied widely, depending on how PTSD has been measured. While record verification of PTSD within mental health outpatient samples has routinely been very low (0%-3%), research assessments of PTSD have resulted in estimated rates of co-occurrence of 29% to 43% (Cascardi, Mueser, DeGirolomo, & Murrin, 1996; Craine, Henson, Colliver, & MacLean, 1998; Mueser et al., 1998). A lack of documentation of PTSD in clinical records and inattention to PTSD in clinical diagnoses are thought to greatly underestimate the extent of PTSD within mental health treatment populations. The general consensus among researchers has been that the occurrence of PTSD is much higher within the population of persons with diagnoses of mental illness than in the general population, particularly among those who have major depression (Friedman & Rosenheck, 1996).

For the most part, the prevalence of PTSD co-occurrence with mental illness is still a matter of speculation (Friedman & Rosenheck, 1996). There are few published rates of documented PTSD diagnoses within large representative samples of people with serious mental illness. A confirmed diagnosis of PTSD requires a clinician assessment using specific criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th edition; DSM-IV; American Psychiatric Association, 1994; Biere, 1997; Blake et al., 1995), a costly undertaking for any research study. Moreover, the debate as to whether general PTSD has distinct comorbid syndromes specific to particular experiences of trauma further complicates the measurement of prevalence (Ford, 1999). To avoid these diagnostic debates and to estimate the prevalence of PTSD in a more pragmatic and general way, researchers have resorted to a variety of research assessment instruments (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Foa, Riggs, Dancu, & Rothbaum, 1993; Zilberg, Weiss, & Horowitz, 1982) and structured interviews designed to solicit memories of traumatic experience (Goodman, Rosenberg, Mueser, & Drake, 1997; Mueser et al., 1998; Weathers, Litz, Herman, Huska, & Keane, 1993). However, identification of PTSD through self-reports and symptom checklists has not yet been standardized, and, while promising instrumentation exists (e.g., Foa, Cashman, Jaycox, & Perry, 1999), the validity and reliability of this instrumentation for the study of co-occurring mental disorders have not been explored. It may well be that disclosing traumatic memories during retrospective research assessments is problematic for people with serious mental illness, triggering the expression of more immediate affect and pain than what the person normally experiences. If so, then existing research estimates of PTSD using self-report methodologies may be overestimates of occurrence.

The present study provides another opportunity to observe the extent of PTSD documentation within the clinical records of a general sample of persons with mental illness, as well as an opportunity to test assumptions regarding the relationship of PTSD to mental illness. Correlates of PTSD and mental illness cooccurrence have generated clinical hypotheses regarding both symptom formation and recovery. Persons diagnosed as having PTSD have been found to have more current or past substance Copyrighted Material abuse, a more chronic history of hospitalizations, and an earlier onset of major depression (Brown & Wolfe, 1994; Zlotnick, Warshaw, Shea, & Keller, 1997) or psychotic symptoms (Greenfield, Strakowski, Tohen, Batson, & Kolbrener, 1994; Paykel, 1978). PTSD has also been associated with poor interpersonal skills, generally low self-esteem, and a pervasive feeling of shame, all of which contribute to isolation and social conflicts (Cresswell, Kuipers, & Power, 1992; Zlotnick et al., 1996). However, the most sophisticated studies of PTSD suggest that the relationship between PTSD and mental illness is reciprocal, with trauma both precipitating and intensifying the symptoms of mental illness, and the symptoms of mental illness in turn increasing the chances that an individual will have a traumatic experience (Horowitz, 1993). For instance, a woman who has suffered repeated physical abuse may want to withdraw from close relationships, but the apathy of depression may not allow her to sever even the one relationship that is abusive. This type of reciprocal cause-effect relationship probably also exists between correlates of PTSD, such as alcoholism and depression (Schutte, Hearst, & Moos, 1997). In this case, the interaction becomes three way, with both drinking and depression inviting the reoccurrence of trauma at the same time as they escalate one another (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997).

This complex cause-effect relationship between PTSD and related variables also suggests that if an individual is able to cope with either the symptoms of mental illness or the impact of trauma, he or she may develop psychological resources that generalize to other life difficulties and actually improve the chances of recovery. Such a possibility is fully realized in the folklore concept of the “wounded healer” and the social work roles assumed by many recovering mental health consumers (Dixon, Hackman, & Lehman, 1997; Mowbray & Moxley, 1997; Solomon & Draine, 1997). What is unique about a pattern of recovery from patient to mental health worker is the return from person-inflicted trauma to fulfilling personal relationships. This readily observable phenomenon suggests that interpersonal vulnerability is both a cause of extreme pain for PTSD victims and a catalyst for growth and emotional maturity.

The present study was designed to explore the complex relationship of PTSD to mental illness and to test the assumption that PTSD typically goes undocumented in a representative sample of persons with serious mental illness. The study compared a group of persons with both mental illness and chart-diagnosed PTSD and a comparison group of persons with serious mental illness but no formal chart diagnosis of PTSD. To the extent that there is a similarity between these two groups in regard to variables theoretically related to PTSD, we assume that there is substantial undiagnosed PTSD within the comparison sample. On the other hand, statistically significant differences between PTSD and no-PTSD groups would suggest that PTSD manifests unique symptoms over and above the depressive symptomatology that characterizes most people with serious mental illness. Meaningful group differences theoretically linked to PTSD would also confirm the general reliability of chart records and suggest that there are not high rates of undetected PTSD within the wider population of persons with serious mental illness.

Method

The present study was conducted as part of the ongoing Employment Intervention Demonstration Program (EIDP) of the federal Substance Abuse and Mental Health Services Administration (SAMHSA). The eight-project EIDP is funded for a period of 5 years (1995–2000) and is distinctive in its inclusion of a coordinating center as well as a common data collection protocol. The present research study was conducted with baseline data from only the Massachusetts EIDP project.

Characteristics of the EIDP Participants

Admission criteria for the EIDP project were (a) 18 years of age or older, (b) a DSM-IV diagnosis of serious mental illness, and (c) absence of severe mental retardation (IQ > 65). The EIDP sample was recruited from within and around the city of Worcester, Massachusetts. The recruitment plan was designed by the project's Advisory Council, composed primarily of representatives from local National Alliance for the Mentally Ill (NAMI) chapters and consumer advocacy groups. A strong effort was made to recruit participants from diverse locations in order to obtain a heterogeneous and representative sample of people with serious mental illness. Referral sources included advocacy organizations, mental health programs, the regional department of mental health, treatment and correctional facilities, and homeless shelters. Applicants who did not have a diagnosis of serious mental illness at the time of referral, but who reported related symptoms, were provided a diagnostic assessment before admission to the project.

The subsample of persons with a diagnosis of PTSD and the comparison subsample of all persons with a diagnosis of major depression without PTSD used in the present analysis were drawn from the total sample of 177 persons recruited for the Massachusetts EIDP. The total EIDP sample was representative of the Worcester-area Department of Mental Health (DMH) population of persons with serious mental illness in regard to all demographic and diagnostic characteristics. About one half (51.8%) of the participants were diagnosed as having a schizophrenia spectrum disorder, 30.7% as having major depression, 16.9% as having bipolar disorder, and 0.6% as having another type of psychotic disorder. Nearly all participants (98%) were on psychiatric medication, averaging 2.75 concurrent medications. The participants generally had a long history of mental illness, with an average of seven hospitalizations beginning at an average age of 25 years. The majority (61%) also had a documented history of serious substance abuse. Two thirds (69%) of the participants received Social Security benefits, with 43% receiving only supplemental security income (SSI). In spite of the chronicity of their illnesses, a large percentage (43%) of study participants were parents, and 20% of the total sample had minor children living with them.

The residential status of participants at the time of enrollment in the project reflects the diversity of recruitment, with 56% (n = 93) living independently, 7.8% (n = 13) in supported or assisted living housing, 16% (n = 21) living as a dependent with their family, and 15% (n = 24) in the hospital. A few participants were in jail (n = 5; 3%) or homeless (n = 4; 3%) at the time of intake.

The work history of participants reflects the debilitating effects of serious mental illness on employment. About half of the sample (55%) had been unemployed for 30 months or longer at the time of enrollment, and 39.4% had not worked at all during the 5 years preceding enrollment in the project. None of the participants held a paying job at the time of entry into the project.

Research Instruments

The data for the present study included (a) clinical information received from referring agencies, the current treating physician, or diagnostic tests conducted by the project and (b) baseline interviews with all project participants. Data collection for the...