POSTTRAUMATIC STRESS DISORDER: PART 1
From PTSD: In an Age of Violence, Terror, and Disaster, presented by the Veterans Affairs Medical Center and the
University of California, San Francisco, School of Medicine
| ADVANCES IN ASSESSMENT OF PTSD—Daniel S. Weiss, PhD, Professor of Medical Psychology, Department
of Psychiatry, University of California, San Francisco, School of Medicine
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| Introduction: to have posttraumatic stress disorder (PTSD), individual must experience “event,” and definition of
event currently problematic; each consecutive edition of Diagnostic and Statistical Manual of Mental Disorders
(DSM) has reconceptualized definition based on epidemiologic work showing that many more people exposed to
traumatic stressors than originally thought; data suggest that 1 in 2 people exposed to traumatic stressor during
their lifetime
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| Traumatic stressor: carries threat of death or serious injury, followed by characteristic set of reactions, including intense
fear, helplessness, horror, revulsion, disgust, panic, immediate numbing and lack of registration of the traumatic
event, disbelief, and/or unreality; individual can be target of or witness to threat; boundaries of what
constitutes traumatic stressor expanding (eg, good evidence indicates that receiving diagnosis of terminal illness
may precipitate same reactions as those that occur in PTSD)
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| Psychologic processes after exposure to traumatic stressor: normal response—reexperiencing or intrusions, coupled
with avoidance; numbing of responsiveness; physiologic arousal; oscillation and seeking of equilibrium (“yes,
it happened; no, it didn’t happen”); dysfunction—occurs when normal process interrupted, blocked, or swamped;
however, speaker cautions that clinical phenomenology of exposure to traumatic stressor “does not neatly fit the diagnostic
criteria” in DSM-IV; in abnormal response, dissociative features often occur early on, but key to whether
individual needs immediate attention is that, after removal of threat or cessation of danger, severe and unremitting
symptoms continue in hours and days after exposure, and normal process of winding down does not occur; dissociative
phenomena—include feelings of unreality (sometimes chaotic) and alterations of time; controversial
whether these phenomena should be included in diagnostic criteria, partly because they are not universal, but they
are important in predicting who will develop PTSD
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| Variants of PTSD: acute PTSD has duration of <3 mo; chronic has duration of ≥3 mo; in delayed onset, symptoms
do not emerge for at least 6 mo; speaker posits that partial PTSD possible (ie, individual may lack 1 or 2 criteria but
has all others), and person who has it needs treatment as much as person who meets full criteria
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| Common comorbidities: depression; substance abuse (especially alcohol); social withdrawal; anxiety; compulsive
preoccupations; nonspecific medical symptoms
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| Predictors of PTSD: speaker’s group evaluated 7 predictors from 68 studies; strongest predictor peritraumatic dissociation,
followed, in order, by perceived support, peritraumatic emotionality, perceived life threat, previous
trauma, previous adjustment, and family history of psychopathology (last 3 equal); limitations of meta-
analysis—assumption that 1) all previous stressors equal, 2) single and multiple exposures equal, 3) time
elapsed after trauma is immaterial, 4) whether event natural or manmade is immaterial, 5) whether event purposeful
or accidental is immaterial, 6) individual responses homogeneous, and 7) all symptoms affected equally
by all factors
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 | Resilience: generally defined as absence of response, rather than specific characteristics that might protect individual
or increase his or her vulnerability
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| Biologic markers: to date, none have been found that are predictors, probably because PTSD involves disruption of
multiple redundant systems, and because humans attribute meaning to their experiences and are self-referential
about them
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| Assessment: many self-report questionnaires available, but not replacements for careful thorough long interview by
experienced professional; allow patient to tell his or her story first; only later, assess symptoms; when allowed to
tell story without interruption, individual eventually comes to place of emotional disruption, indicating issue that
has key meaning for him or her; many patients express guilt, even if there was nothing they could have done to
prevent or mitigate trauma
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| Assessment measures: Clinician-Administered PTSD Scale (CAPS) current state of art in research; may be helpful
for clinical applications as well; available at National Center for PTSD Web site (http://www.index.va.gov);
assists in systematic assessment of 17 core symptoms, and helps determine frequency and
intensity of symptoms
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| Summary: consider Osler’s observation, “it is more important to know what patient has a disease than what disease
a patient has”; not necessary for patient to meet full diagnostic criteria to experience suffering or substantial impairment;
counter stigma by conceptualizing PTSD as event-related psychologic injury, not as due to weakness and
not as source of shame; normal response to traumatic stressors involve same phenomena as those in PTSD
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| INTEGRATIVE PSYCHOTHERAPY FOR PTSD—Mardi Horowitz, MD, Professor of Psychiatry, University of
California, San Francisco, School of Medicine
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| Integrative psychotherapy: psychotherapist should put together (ie, integrate) all methods that offer help for patients;
in addition, psychotherapist tries to integrate patient’s personality in hope that, in recovering from traumatic
experience, patient will also grow
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| “The big principles”: diagnosis inot enough, because individual encounters trauma in context of his or her personality
and experiences, with his or her habitual strengths and weaknesses; formulate stress in light of patient’s personality
to plan how he or she can change; formulate trauma in context in which it occurred (eg, some people, such as
those who seek risky situations, have personalities that evoke traumas; some traumas subintended suicides); lives
often made more complex because every trauma creates cascade of traumas; eg, person who has been in single accident
may be stressed by whether ambulance arrived in timely manner, how ambulance attendants spoke to him or
her, what happened in emergency room, whether cardiopulmonary resuscitation or intubation necessary, and
whether hospital admission necessary, in addition to issues involving police, insurance, finances, relatives, and so
on; any or all of these things can be “kind of indigestible to the mind, depending on the preexisting patterns of
meaning that are imbedded in the patient’s personality”; treatment methods shift as phases of response change; eg,
empirical studies show exposure therapy most effective treatment for PTSD , but studies defined by simplified
method that does not account for complexity of PTSD; as well, “the fact that treatment is found by a committee to
be effective does not mean that other treatments are not effective”; clinician must use every form of therapy likely
to help patient
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| Phases of response: 1) outcry—victims seldom seen in this phase; when disaster occurs, many mental health practitioners
make themselves available to help, but patients may not seek help; select who can be helped by debriefing
on individual basis; human factor of crucial importance; eg, soldiers who feel they have poor leadership more
likely to develop stress-response syndrome, and people who feel alienated, stigmatized, neglected, or abandoned
more likely to have stress-response syndrome, given same intensity of exposure; 2) denial, numbing, and
avoidances—adaptive feature of human mind in which individual does what is necessary to deal with immediate
crisis and reacts later; 3) intrusions, pangs, and repetitions—therapist often tries to help dampen these reactions,
but also to help patient experience them in different state of mind, one in which patient feels more competent,
hopeful, and safer; trauma dangerous, and therapist tries to create safe haven in which patient can forget or remember;
4) working through—trying to create sense of patient’s being in control and facing ideas that must be articulated
into his or her personality and life story; patients cannot make trauma go away, but can make some of their
fantasy elaborations of it into realistic appraisals; 5) restoration of equilibrium—includes trying to create posttraumatic
growth; aspects of personality include person’s abilities, capacities, strengths, resilience, and prior experiences;
humans have basic resilience to trauma because we have always had it in our lives
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| Biopsychosocial considerations: “everything’s connected to everything”(ie, biologic, psychologic, and sociologic
aspects interact); biologic—important to note that synaptic hypersensitivities and inhibitions occur, and therapist
unable to stop this; however, therapist can help patient modify relative activation of different ideas, which are
based on physiologic sensitivity (ur-defenses); psychologic—emotional information processing can be modified
with therapist’s help; sociologic—societies have memes for how people are supposed to react to trauma; these are
social stereotypes hidden in the subconscious; therapist must be cognizant of patient’s social stereotypes and subcultural
sensitivities
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| Stages of treatment: goal of integrated psychotherapy is to go through stages quickly until patient is well, as defined
by patient, therapist, and sometimes outside agencies such as government or insurance carrier
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| Evaluating patient and negotiating treatment plan: patient reports symptoms, events, and contexts; therapist takes
history, makes diagnosis and initial formulation, educates patient, and discusses treatment options; patient and
therapist agree on provisional treatment plan; many patients caught up in issues that involve forensics, reparations,
disability, payment, entitlement, and insurance; important to discuss those issues upfront in first session
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| Stabilizing patient’s state through initial support: some patients may not need this and others may need it for extended
period; do not proceed to deeper levels of interpretation until patient feels in control and has sense of hope
that he or she can work things through; ask how patient is coping with having stress-related syndrome; educate
patient about common manifestations of PTSD and how to take care of himself or herself; ≥50% of all patients
with stress-related syndrome abuse substances, which may compromise their ability to work through trauma;
therapist needs to counteract demoralization and exhaustion; counsel patient to avoid excessive stimuli and to get
every confidante engaged with him or her, but advise patient that he or she may be irritated by or irritating to
those confidantes; use dose-by-dose approach and encourage respite between doses; tell patient what you are doing
and why; advise patient that it is helpful to help others if he or she is able; instruct patient in relaxation and
positive-psychology techniques
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| Exploration of meanings: includes previous personality meanings; ascertain patient’s appraisal of meanings of his
or her symptoms; in this stage, topics of concern to patient usually include more intrusive symptoms and emotional
regulation; topics that lead to defensive disavowal and shimmering states of mind often those that are unresolved;
explore identity and relationship meanings, which tend to come late and may not need to be explored if
treatment successful at earlier stages; when patient begins to feel hopeful but “sort of stops talking,” ask, “what’s
the meaning of that event to you now?” general topic of concern is meaning of the trauma to the self; people may
have multiple self-images, and these may regress under stress; traumatic events usually involve loss (or threat of
loss) of identity, and this issue needs to be explored; patient’s self-image may shift from competent to incompetent,
from attractive to unattractive, from strong to weak (or childlike), from coherent to chaotic sense of self-regard;
patient may experience depersonalization
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| Improving patients’ capacities and coping skills: work from relative simplicity of desensitization to finding new
ways of being helpful to other people; patient works on plans for near future and addresses unresolved themes that
he or she previously avoided; therapist acts to encourage desensitization, to increase safe exposures while avoiding
retraumatization, and to counteract excessive defenses; both patient and therapist work toward modification of
dysfunctional beliefs about future and past
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| Working through: exploration of “things that are sticky and repetitive and that may have unconscious meanings attached
to the stressful event”; patient reconstructs trauma story and reschematizes identity and relationships;
therapist encourages safe encounters, challenges dysfunctional ideas, counters excessive defenses, and clarifies
wish-fear dilemmas; patient and therapist work on differentiating reality from fantasy; “a great human morale
builder is work; work occupies attention; it creates concentration; it creates self-worth; even makes money sometimes”;
finding some kind of job where patient can have restoration of identity and building of relationships with
others important to recovery process
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| Termination: cannot be abrupt; patient confronts unfinished issues, and copes with loss of therapy relationship;
therapist clarifies patient’s gains, work yet to be done, and issues for future; therapist anticipates and counteracts
patient’s regressions; both place emphasis on safe separation and explore differences between this separation and
separation themes brought out by trauma
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| Conclusions: therapist rarely able to “figure out everything” during initial evaluation; start with hope, support, and
provisional plan; gradually formulate and reformulate treatment plan; recognize own stress from empathic responses;
“in the midst of winter, I finally learned that there was in me an invincible summer” (Albert Camus)
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Suggested Reading
Avrahami D: Visual art therapy’s unique contribution in the treatment of post-traumatic stress disorders. J Trauma
Dissociation 6:5, 2005; Brunet A et al: The Peritraumatic Distress Inventory: a proposed measure of PTSD criterion
A2. Am J Psychiatry 158:1480, 2001; Fikretoglu D et al: Peritraumatic fear, helplessness and horror and peritraumatic
dissociation: do physical and cognitive symptoms of panic mediate the relationship between the two? Behav
Res Ther 45:39, 2007; Ford JD et al: Treatment of complex posttraumatic self-dysregulation. J Trauma Stress
18:437, 2005; Horowitz MJ: Understanding and ameliorating revenge fantasies in psychotherapy. Am J Psychiatry
164:24, 2007; Kellermann NP: Transmission of Holocaust trauma—an integrative view. Psychiatry 64:256, 2001;
Neylan TC et al: Attention, learning, and memory in posttraumatic stress disorder. J Trauma Stress 17:41, 2004;
Neylan TC et al: Temporal instability of auditory and visual event-related potentials in posttraumatic stress disorder.
Biol Psychiatry 53:216, 2003; Ozer EJ et al: Predictors of posttraumatic stress disorder and symptoms in adults: a
meta-analysis. Psychol Bull 129:52, 2003; Schlenger WE et al: The psychological risks of Vietnam: the NVVRS
perspective. J Trauma Stress 20:467, 2007; Steele K et al: Phase-oriented treatment of structural dissociation in complex
traumatization: overcoming trauma-related phobias. J Trauma Dissociation 6:11, 2005; Sundin EC, Horowitz
MJ: Horowitz’s Impact of Event Scale: evaluation of 20 years of use. Psychosom Med 65:870, 2003; Sundin EC,
Horowitz MJ: Impact of Event Scale: psychometric properties. Br J Psychiatry 180:205, 2002.
Educational Objectives
| The goal of this program is to improve the diagnosis and treatment of posttraumatic stress disorder (PTSD). After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Assess the severity and duration of stress-related disorders, including PTSD.
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| 2. Explain the psychologic processes that occur after exposure to a traumatic event.
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| 3. Discuss some of the predictors for developing PTSD.
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| 4. Describe the principles of integrative psychotherapy for PTSD.
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| 5. Summarize the states of integrative psychotherapy.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee members
to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Drs. Weiss and Horowitz were recorded at PTSD: In an Age of Violence, Terror, and Disaster, held November 9-10,
2007, in San Francisco, CA, and sponsored by the Veterans’ Affairs Medical Center and the University of California, San
Francisco, School of Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in
the production of this issue.
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