Psychiatry -Topic posttraumatic stress disorder (PTSD)
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posttraumaticstressdisorderPTSD..docxBook Crisis Intervention Strategies
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Richard K. James; Burl E. Gilliland |
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Introduction to posttraumatic stress disorder (PTSD).
Part II’s discussion of the more common types of cri- ses that you, as a mental health worker or consumer of mental health care, are likely to encounter opens with posttraumatic stress disorder (PTSD). The reason for beginning here is that many other crises reviewed in this book may be rooted in PTSD. For ex- ample, suicide (Chu, 1999; Kramer et al., 1994) and substance abuse (Ouimette, Read, & Brown, 2005; Read, Bollinger, & Sharansky, 2003) may be the end products of attempting to cope with trauma. In contrast, rape, sexual abuse, battering, loss, physical violence, hostage situations, and large-scale natural and human-made disasters may precipitate the dis- order (Ackerman et al., 1998; Bigot & Ferrand, 1998; Darves-Bornoz et al., 1998; Davis et al., 2003; Elklit & Brink, 2004; King et al., 2003; Lang et al., 2004; Melhem et al., 2004; North, 2004; Pivar & Field, 2004). Going one-on-one with PTSD is tough enough, but to make matters worse, lots of times PTSD turns into a gang war with a host of other comorbid (occurring along with it) problems that make it even harder to deal with as individuals bounce in and out of trans- crisis (Masino & Norman, 2015). Finally, PTSD-like symptoms may appear in the very people who attempt to alleviate the mental and physical suffering of peo- ple in crisis (Figley, 2002; Halpern & Tramontin, 2007; Pearlman & Saakvitne, 1995) and have become known as compassion fatigue (Figley, 2002) and vicar- ious traumatization (Pearlman & Saakvitne, 1995). We know this is a long chapter and you might need to take a nap or a snack break to get through it. Try as we might to prune it down, we felt that “all this stuff” was critical to giving you the background for understanding not only what PTSD is about, but what occurs in treating the other crisis and transcri- sis topics in this book. What we knew about PTSD in the first edition of this book in 1987 and what we know about it now—particularly the neurobiology and just how complex that is in manifesting the various traumatic responses that occur in humans— is like the difference between writing with a goose quill, inkwell, and papyrus scroll and word process- ing with an Apple Thunderbolt, OSX Lion operating system, and high-speed printer/scanner/fax. So bear with us! If you nail this chapter down, the other chapters will make a whole lot more sense as to how “all this stuff” goes together. In summary, PTSD has moved from the psychological backwaters of the Vietnam War to now being so central to treatment issues in mental health that there is the National Center for PTSD (http://www.ptsd.va.gov) and the National Child Traumatic Stress Network (NCTSN) www.nctsn.org.
Background
Psychic trauma is a process initiated by an event that confronts an individual with an acute, overwhelming threat (Freud, 1917/1963). When the event occurs, the inner agency of the mind loses its ability to control the disorganizing effects of the experience, and disequilibrium occurs. The trauma tears up the individual’s psychological anchors, which are fixed in a secure sense of what has been in the past and what should be in the present (Erikson, 1968). When a traumatic event occurs that represents noth- ing like the person’s experience of past events, and the individual’s mind is unable to effectively answer basic questions of how and why it occurred and what it means, a crisis ensues. The traumatic wake of a crisis event typically includes immediate and vivid reexperi- encing, hyperarousal, and avoidance reactions, which are all common to PTSD. The event propels the indi- vidual into a traumatic state that lasts as long as the mind needs to reorganize, classify, and make sense of the traumatic event. Then, and only then, does psy- chic equilibrium return (Furst, 1978).
The typical kinds of responses that occur imme- diately after the crisis may give rise to what are called peritraumatic (around, or like, trauma) symptoms. These are common responses as the mind attempts to reorganize itself and cope with a horrific event. For many people, these responses will slowly disappear af- ter a few days. Most people are amazingly resilient in the aftermath of a traumatic crisis and quickly return to mental and physical homeostasis, but if the symp- toms continue for a minimum of 2 days and a max- imum of 4 weeks and occur within 1 month of the traumatic event, then those time frames will meet the criteria of acute stress disorder (ASD) (American Psychiatric Association, 2013). Acute stress disorder diagnostic criteria are similar to the criteria for PTSD, which you will soon meet, except that the diagnosis can only be given in the first month after a traumatic event. ASD is somewhat different than PTSD be- cause dissociative symptoms such as memory loss, a sense of detachment from the world, belief that things and people are unreal, a blurred sense of iden- tity, and a general disconnect from reality are present (International Society for the Study of Trauma and Dissociation, 2015). As we will see, it is important to tackle ASD symptoms immediately and head on, be- cause they tend to be valid predictors for “catching” PTSD. Percentage rates for ASD vary a great deal de- pending on trauma type from vehicle accidents that range in the teens, to victims of robbery in the twen- ties, and to rape which skyrockets to the nineties (Gibson, 2015).
If the person can effectively integrate the trauma into conscious awareness and organize it as a part of the past (as unpleasant as the event may be), then homeostasis returns, the problem is coped with, and the individual continues to travel life’s rocky road. If the event is not effectively integrated and is sub- merged from awareness, then the probability is high that the initiating stressor will continue to assail the person and become chronic PTSD. It may also dis- appear from conscious awareness and reemerge in a variety of symptomatic forms months or years after the event. When such crisis events are caused by the reemergence of the original unresolved stressor, they fall into the category of delayed PTSD (American Psy- chiatric Association, 2013).
PTSD is a newborn compared with the other crises we will examine, at least in regard to achieving official designation. In 1980, PTSD found its way int the third edition of the American Psychiatric Associa- tion’s (1980) Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as a classifiable and valid mental disorder. However, the antecedents of what has been designated as PTSD first came to the attention of the medical establishment in the late 19th and early 20th centuries.
Two events serve as benchmarks in the history of PTSD. First, with the advent of rail transportation and subsequent train wrecks, physicians and early psychiatrists began to encounter in accident survivor’s trauma with no identifiable physical basis. Railway accident survivors of this type became so numerous that a medical term, railway spine, became an accepted diagnosis. In psychological parlance, the synonymous term compensation neurosis came into use for invalidism suffered and compensated by insurers as a result of such accidents (Trimble, 1985, pp. 7–10).
Concomitantly, Sigmund Freud formulated the concept of hysterical neurosis to describe trauma cases of young Victorian women with whom he was working. He documented symptoms of warded-off ideas, denial, repression, emotional avoidance, com- pulsive repetition of trauma-related behavior, and recurrent attacks of trauma-related emotional sen- sations (Breuer & Freud, 1895/1955). However, what Freud found and reported on the pervasive childhood sexual abuse of these women as the traumatic root of their hysteria was anathema to a puritanical Victo- rian society, and he was forced to disavow and then reject his findings (Herman, 1997, pp. 13–17).
Second, the advent of modern warfare in World Wars I and II, with powerful artillery and aerial bom- bardment, generated terms such as shell shock and combat fatigue to explain the condition of trauma- tized soldiers who had no apparent physical wounds. As early as the American Civil War, soldiers were di- agnosed with neurasathenia, a state of mental and physical exhaustion. This malady was also termed “soldier’s heart” because of the belief that nerves at the base of the heart were somehow affected by com- bat. The term nostalgia, a 19th-century military term coined by physicians for combat soldiers with extreme homesickness, would be seen as combat- induced PTSD in current terms. The thought was that soldiers became nostalgic for home and thus started to manifest a variety of physical symptoms that would relieve them from combat and allow them to go home (Kinzie & Goetz, 1996). Various hypothe- ses such as the foregoing were proposed to account for such strange maladies (Trimble, 1985, p. 8), but Freud (1919/1959) believed that the term war neurosis more aptly characterized what was an emotional disorder that had nothing to do with the prevailing medical notion of neurology-based shell shock, the idea that concussion from the massive shelling common in World War I injured the brain’s neurological systems. The U.S. Medical Service Corps came to recognize combat fatigue (being on the front line too long) in World War II and the Korean War as a treatable psy- chological disturbance. The treatment approach was that combat fatigue was invariably acute and that treatment was best conducted as quickly and as close to the battle lines as possible. The idea was to facilitate a quick return to active duty. The prevailing thought was that time heals all wounds and that little concern needed to be given to long-term effects of traumatic stress. Such has not been the case (Archibald et al., 1962). Indeed, a notable proponent of establishing the Vietnam Veterans Centers, Arthur Blank, ruefully commented that when he was an army psychiatrist in Vietnam, he believed there would be no long-term dif- ficulties for veterans (MacPherson, 1984, p. 237).
Although PTSD can and does occur in response to the entire range of natural and human-made catas- trophes, it was the Vietnam War that clearly brought PTSD to the awareness of both the human services professions and the public. Through a combination of events and circumstances unparalleled in the military history of the United States, veterans who returned from that conflict began to develop a variety of men- tal health problems that had little basis for analysis and treatment in the prevailing psychological litera- ture. This combination of events and circumstances had insidious and long-term consequences that were not readily apparent either to the individuals affected or to human services professionals who attempted to treat them. Misdiagnosed, mistreated, and misunder- stood, military service personnel became known to a variety of social services agencies that included the police, mental health facilities, and unemployment offices (MacPherson, 1984, pp. 207–330, 651–690).
As the war continued to grind on, more and more veterans started having psychological problems. Re- buffed by the Veterans Administration, these veterans formed self-help groups to try to come to terms with their psychological issues. These “rap” groups rapidly coalesced and became a political force that pushed the federal government to come to grips with their problems. One major result of their lobbying efforts was the establishment of the Vietnam Veterans Centers, where alienated veterans could seek help for a variety of readjustment problems. An informal network of mental health professionals became interested in the veterans and started to classify their symptoms and compare them to the work Kardiner (1941) had done on war neurosis. Their review of clinical records led them to generate 27 of the most common symptoms of the Vietnam veterans’ “traumatic neurosis” (van der Kolk, Weisaeth, & van der Hart, 1996, p. 61). Interestingly, many of the physical or somatic complaints resemble those of a large retrospective archival study on the medical records of American Civil War Union veterans (Pizarro, Silver, & Prause, 2006)!
At the same time, researchers in the growing women’s movement were looking at psychological problems after domestic violence, rape, and child abuse. What they were finding in the individuals who had suffered from these civilian assaults closely paralleled the problems that Vietnam veterans were experiencing. Their research rediscovered what Freud had found 80 years before and had dismissed: that victims of physical and sexual assault suffered long-term effects of the psychological trauma (Herman, 1997, p. 32). These different research avenues culminated in combining the “Vietnam veterans syndrome,” the “rape trauma syndrome,” the “abused child syndrome,” and the “battered woman syndrome” into one diagnostic category—posttraumatic stress disorder—in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual in 1980 (van der Kolk, Weisaeth, & van der Hart, 1996, p. 61).
Although the Vietnam War may be no more to you than a reference in a high school history book, the wall memorial in Washington, DC, or your “crazy old Uncle Harold” who continues to wear combat fatigues and a headband with a ponytail, the war’s effects are a crucial history lesson in mental health provision (or the lack thereof) that any aspiring mental health worker should learn. For that reason, the psychological lessons learned from the Vietnam War continue to play a major role in the discussion of PTSD in the eighth edition of this book. It should be clearly under- stood that, even 50 years after the fact, the events that caused the trauma in many of these approximately 1 million veterans who suffered and suffer from PTSD are as alive for them today as they were then (Price, 2011). What is perhaps even more ominous in regard to the Vietnam veterans is their “graying.” Mounting evidence indicates that World War II and Korean War veterans have manifested delayed onset or worsening of posttraumatic complaints as they have grown older.
Aging, with its subsequent loss of social supports through death, increased health problems, declining physical and mental capabilities, and economic hard- ship, appears to put older veterans at increased risk (Aarts & Op den Velde, 1996, pp. 359–374; Hamilton & Workman, 1998). Thus, it would appear that as this population ages, the mental health professions are a long way from being done with the legacy of Vietnam.
Perhaps even more ominous, the current wars in Iraq and Afghanistan have eerily similar parallels to Vietnam. There are no front lines, the enemy fades into the population, everyone in the theater of operations is essentially in combat. As a result, vigilance must be constant, 24/7, throughout one’s entire rotation. Degree of combat exposure has been found to be one of the major predictors of PTSD (Miller et al., 2008; Smith et al., 2008), and anybody that goes into the “sandboxes” as they now called can expect just that.
There are two major differences in these conflicts. So far there is general public support for the troops, whereas in Vietnam there was not. A support group is critical in any crisis, and this is particularly true of troops in an increasingly unpopular war. Lack of support and outright hatred of returning troops was a major contributing factor for PTSD in Vietnam veterans. However, while the armed forces in the current conflicts are all volunteers and not 18-year-old draftees, there are a tremendous number of reserve units in combat action, and there are also huge differences in the number of women involved in direct combat action. The question then becomes what the use of reservists and women in combat portends for the on- set of PTSD. Preliminary results regarding mental health problems in veterans returning from Iraq and Afghanistan have ranged from 19% to 44% of the samples examined (Hoge, Auchterlonie, & Milliken, 2006; Lapierre, Schweigler, & LaBauve, 2007).
Dynamics of PTSD
Diagnostic Categorization
PTSD is a complex and diagnostically troublesome disorder. To be identified as having PTSD, a person must meet the following conditions and symptoms as specified in the Diagnostic and Statistical Manual-5 (American Psychiatric Association, 2013). In the new DSM-5, a subcategory for children under 6 years of age has also been formulated. The following criteria are specific to adults, adolescents, and children older than 6. Examples have been pro- vided to illuminate the specific criteria .
First, the person must have been exposed to a trauma in which he or she was confronted with an event that involved actual or threatened death or serious injury or actual or threatened sexual violence. Then the person must meet the following criteria for a diagnosis of PTSD.
Criterion A. That exposure must include one of the following stressors:
1. Direct exposure to the experience
2. Or witnessing its occurrence.
3. Indirectly by learning that a significant other was exposed to a trauma that involved actual or threatened death either by a violent or accidental event.
4. Repeated or extreme exposure to aversive details of the event most usually through professional duties associated with it such as EMTs working accidents where dead and mangled bodies are present or therapists working child abuse cases. Vicarious exposure of nonprofessionals through watching or listening to electronic media does not meet this criterion. Examples include but are certainly not limited to military combat, physical or sexual assault, kidnapping, being held hostage, severe vehicle accidents, earthquakes and tornadoes, being a refugee from a war zone, concentration camp detention, and life-threatening injuries or illness.
Criterion B. The traumatic event is reexperienced through at least one of the following intrusive symptoms:
1. Recurrent, involuntary, and intrusive memories. These occur despite efforts or admonitions to “forget it and move on.” In children intrusion may occur through repetitive play.
2. Traumatic nightmares. Typically, they regularly occur and are terrifying enough that alcohol or other mind-altering substances are used to dampen their onset and diminish their effect. In children nightmares occur which may have no apparent relation to the traumatic event.
3. Dissociative reactions or flashbacks to the traumatic event which may range from brief, momentary episodes, to complete loss of consciousness. These flashback episodes, including those that occur on awakening or when intoxicated, may include all types of sensory hallucinations or illusions which cause the individual to dissociate from the present reality and act or feel as if the event were recurring. Children may dissociate through play by reenacting the event.
4. Intense or prolonged distress after being exposed to stimuli that spark reminders of the traumatic event; such as anxiety/panic attacks, excessive and obsessive worry and concern.
5. Marked physiological responses upon exposure to traumatic stimuli. An example such as a person who was in a tornado starting to shake violently at every approaching storm.
Criterion C. The person engages in persistent and purposeful effort to avoid distressing stimuli that are reminiscent of the event through one of the following methods:
1. Trauma-related thoughts or feelings; such as impeding thoughts of doom or feelings of hopelessness.
2. External reminders of the events such as people, objects, situations, activities, conversations that trigger negative memoires.
Criterion D. The person experiences negative altera- tion in cognitions and mood after the experience in at least two of the following ways:
1. Excluding head injury drugs or alcohol abuse, the person cannot remember key features of the traumatic event. Memory of the event is foggy, distorted, repressed, or jumbled as to sequence, place, persons, or time.
2. There are persistent and often distorted negative beliefs about oneself or the world such as “I am a bad person” and “the world is a terrible and dangerous place.”
3. There is persistent and distorted blame for oneself or others for causing the traumatic event.
4. The person experiences persistent trauma-related negative emotions such as fear, horror, anger, sadness, guilt, shame.
5. Markedly diminished interested in pre-traumatic activities that include hobbies, recreations, work, avocations, organizations, and other pastimes.
6. The individual feels alienated from others and is estranged or detached from significant others. 7. Affect of the person is constricted such that he or she has persistent inability to experience positive emotions.
Criterion D includes many of the symptoms that were included in the DSM-IV-R (American Psychi- atric Association, 2000) criteria under “Numbing” (Marx & Gutner, 2015). We believe that exclusion deserves an editorial comment with all due respect to the developers of the current criteria. One of the classic signs of an individual who has PTSD are the emotional “numbing” effects it leaves. We believe that the current descriptors really don’t do service to this hallmark symptom and is something that neophyte interventionists needs to be aware of and look for when assessing for PTSD.
Criterion E. The individual has trauma-related alterations in arousal and reactivity that began or became worse after the traumatic event. At least two of the following criteria are required.
1. Irritable or aggressive behavior; such as picking a fight for no apparent reason.
2. Self-destructive or reckless behavior; such as legal but highly dangerous behavior like free hand rock climbing up 90-degree cliffs or illegal behavior such baiting the police while driving recklessly.
3. Hypervigilance; which may result in overprotective behavior of significant others or extreme paranoia about objectives that were previously associated with threat such as being extremely restrictive of children’s recreational activities or swerving to avoid a dead animal carcass along the highway that when in the service was previously known to be a place to conceal explosives in wartime.
4. Exaggerated startle response; examples of noises previously associated with threat such as engine backfires, carpenter nail guns, news helicopters, or sudden movements of other persons such as children sneaking up on parents or partners/ bedmates jostling.
5. Problems in concentration; where previously tasks could be accomplished with ease are now difficult to do so, or train of thought is lost while attempting to do them.
6. Sleep disturbance, not only due to nightmares but to any nighttime uncommon noises, movements of others.
Criterion F. The duration of the foregoing symptoms persists more than 1 month.
Criterion G. There are significant symptoms of any of the foregoing criteria that cause enough related distress or ability such that the individual is unable to function either socially or occupationally.
Examples are divorce and alienation from family, inability to keep and hold jobs, and starting and dropping out of educational programs.
Criterion H. The disturbance is not due to medication, substance use, or other illnesses. Additionally, the person may be specified as having PTSD along with dissociative symptoms if they report either:
1. Depersonalization as if the person is watching herself from a grandstand or seeing herself as in a movie such that it can’t really be happening to her.
2. Derealization as if this is unreal and can’t be happening, or the images become distorted and blurred and are hard to sort out and make sense of them
At times, full criterion onset may be delayed for at least 6 months or more, although onset of some of the symptoms may occur immediately. It should become clear that because of the multiple, specific criteria for a diagnosis of PTSD, not everybody who undergoes a traumatic event automatically “catches” PTSD. Also, it should be apparent from the foregoing criteria that what the crisis interventionist is going to be dealing with are the trans crisis symptoms that exist in the foregoing criteria and arise unbidden into the individual’s life. As stated previously in Chapter 1, while PTSD invariably involves multiple trans crisis events and situations, trans crisis does not always involve PTSD, such as in the case of domestic violence, alcohol abuse, or school bullying.
Complex PTSD
The DESNOS classification opens a Pandora’s box of psychological evils that include the inability to regulate feelings, suicidal and other self-destructive behaviors, impulsive and dangerous risk-taking behaviors, anger management problems, amnesia and dissociation from reality, somatic complaints that take a variety of physical forms, chronic character changes that range from consuming guilt to permanent ineffectiveness in coping with life, adopting distorted and idealized views of perpetrators of the trauma, an inability to trust others, a tendency to victimize or be revictimized, and despair and hopelessness that previously held beliefs about a “fair and just” world are no longer valid. Typical in- habitants of a DESNOS world are persons with long- term exposure to combat service, adult survivors of chronic childhood sexual and physical abuse, and concentration camp survivors. Whether simple or complex, it should be readily apparent that PTSD is an extremely serious condition with all kinds of associated problems and comorbid mental illness (Masino & Norman, 2015) and that the DSM-5 criteria do not begin to depict all the consequences and ef- fects of the disorder that assail the individual and ripple out to significant others in the individual’s life.
Conflicting Diagnoses
Given the wide variety of maladaptive behaviors that characterize the disorder, it is not uncommon for those who suffer from PTSD to have companion diagnoses of anxiety, depressive, organic mental, and substance use disorders (American Psychiatric Association, 2000, p. 427). In fact, it is probably more common to have comorbidity (the presence of two diagnosable disorders such as major depression and substance abuse) ( Marx & Gutner, 2015). Further, be- cause of presenting symptoms, PTSD may be confused with adjustment, paranoid, somatic, and personality disorders (Herman, 1997, pp. 116–117; Zanarini et al., 1998; Zlotnick et al., 1999).
One of the hallmarks of PTSD is that it is often comorbid—particularly with alcohol abuse (Najavits, 2012; Ouimette & Read, 2014). That is, the person will have another preliminary mental illness diag- nosed in the course of treatment. There are few “pure” cases, and few symptoms are unique to the disorder (Atkinson, Sparr, & Sheff, 1984; Masino & Norman, 2015). Thus, no matter what the diagnosis, assessment in crisis intervention should always attempt to determine if there has been exposure to prior trauma, particularly when the crisis seems to have occurred spontaneously, with no clear, immediate, precipitating stimulus. The Question of Preexisting Psychopathology For a variety of political and social reasons,
society does not perceive (and has not perceived) being a victim of war, domestic violence, or other types of human cruelty as the equivalent of being mentally ill. Vietnam veterans who early on sought help from Veterans Administration (VA) hospitals were misdiagnosed or thought to have some preexisting psycho- pathology or character disorder. As a result, they were revictimized by a bureaucratic and rigidly conservative mental health system that added psychic insult to psychic injury (Ochberg, 1988, p. 4). Victims of domestic violence fared no better and were often seen to have a “masochistic” personality that subconsciously enjoyed physical assaults (Herman, 1997, p. 117). Such revictimization and discounting by supposedly “caring” professionals exacerbate the trauma survivor’s problems exponentially.
There is evidence of a heritable component to the transmission of PTSD (Glatt et al., 2013; Skelton et al., 2012) and to one’s ability to be resilient to its assaults (Southwick & Watson, 2015). Undoubtedly some people, because of a previous psychiatric his- tory, are more predisposed to breaking down under stress than are others (Norris et al., 2002; Ullman & Siegel, 1994). Furthermore, the number and magnitude of the trauma will predict higher potential for PTSD (Norris et al., 2002; Shalev, 1996, p. 86). Expo- sure to multiple rapes, being held in a concentration camp, extended child abuse, the loss of loved ones, or prolonged frontline combat typically puts the individual at far greater risk for PTSD than a onetime physical assault by a parent or an auto accident in which no one was killed. Additionally, lack of education, community support, chronic child abuse, low economic status, increased number in family, gender (females are seen as at greater risk), age (younger age at time of event), marital status (not married), and lack of family support systems have all been seen as contributing factors for developing PTSD (Jovanovic) et al., 2004; Myers & Wee, 2005; Norris et al., 2002; Southwick & Watson, 2015; Suar & Khuntia, 2004; Wilson, Friedman, & Lindy, 2001). However, no absolute factors guarantee that one person as opposed to another will develop PTSD. Brewin (2005) found that although there are a num- ber of risk factors for PTSD, their effect sizes tend to be small and vary according to the nature of the trauma. Given the right conditions, it appears anyone can be a candidate. The collapse of a concrete walkway in a crowded hotel gives us a prime example of how one event may suddenly produce PTSD symptoms. Biographical data gathered following the Kansas City Hyatt Regency skywalk disaster revealed that few survivors had character disorders before the event. Yet 6 months after the event, many were suffering from a variety of presenting symptoms (Wilkinson, 1983). White (1989) found the same result in a study of burn victims suffering PTSD symptoms. The overwhelm- ing majority of these individuals had no previous psy- chiatric history. Probably the best summing statement about who will and who will not manifest PTSD was made by Grinker and Spiegel (1945) in their study of World War II veterans. They concluded that no matter how strong, normal, or stable a person might be, if the stress were sufficient to cross that particular indi- vidual’s threshold, a “war neurosis” would develop. It should also be clearly understood that PTSD is not culture bound. While there are variations on the theme cross-culturally, there is a great deal of evidence that PTSD is a cross-cultural phenomenon common to all people (Brewin, 2003; Marsella et al., 1996). In summary, susceptibility and ability to be resilient to PTSD is a function of several factors: ge- netic predisposition, ecological factors, constitution, personality makeup, previous life experiences, state of mind, cultural artifacts, phase of maturational de- velopment at onset, spiritual beliefs, social support system before and after the trauma, and content and intensity of the event (Brewin, 2003, 2005; DeVries, 1996; Furst, 1967; Green & Berlin, 1987; Halpern & Tramontin, 2007; Kaniasty & Norris, 1999; Norris et al., 2002; Shalev, 1996; Southwick & Watson, 2015; Wilson, Friedman, & Lindy, 2001).
Neurophysiological Responses
In the last 20 years a tremendous number of psychobiological studies have conclu- sively demonstrated that trauma affects the individual in a variety of physical ways. Researchers have discovered that neurotransmitters, hormones, cortical areas of the brain, and the nervous system play a large role in PTSD (Daniels et al., 2013; Herringa et al., 2013; Lanius, Bluhm, & Frewen, 2013; Lu et al., 2013; Macdonald, Franz, & Vasterling, 2012; Roths- child, 2000; Schore, 2013; Tyrka et al., 2013; van der Kolk, 1996a; Vasterling & Brewin, 2005). Putting this complex neurobiological puzzle together has tremen- dous ramifications about what kinds of drug thera- pies might be used in its treatment. When a person is exposed to severe stress, neurotransmitters, neuromodulators, hormones, endogenous opioids, and specific cortical functions designed to deal with the emergency are activated (Grinker & Speigel, 1945; Santa Ana et al., 2006; Selye, 1976; Siegel, 1995; van der Kolk, 1996a, pp. 215–234; Vermetten & Bremner, 2002). Although cessation of the traumatic event may remove the person from dan- ger and no longer require the body’s system to function on an emergency basis, if the stress is prolonged, the nervous system may continue to function in an elevated and energized state as if the emergency were still continuing (Burgess-Watson, Hoffman, & Wilson, 1988; van der Kolk, 1996a, pp. 214–234). Furthermore, there is evidence that intense and continuous stress can cause permanent physical changes in the brain (Copeland, 2000; Daniels et al., 2013; Malizia & Nutt, 2000; McDonald, Franz, & Vasterling, 2012; Vermetten & Bremner, 2002). These changed physiological states are important because they not only cause individuals extreme physical and psychological duress long after the traumatic event but also help explain why people do not “get over” PTSD. In their study and review of the neuroanatomical correlates of the effects of stress on memory, Bremner and associates (1995, 1997) and Gurvitz, Shenton, and Pittman (1995) found in combat veterans significant decreases in the hippocampal area of the brain where explicit memory encoding, memory consolidation, and organization take place, as did Stein and associates (1994) in women who had experienced severe child sexual abuse. Whether the smaller hippo- campus is a causal factor for PTSD or PTSD causes the hippocampus to become smaller is not known. However, Astur and associates’ (2006) study of identified PTSD experimental subjects versus non-PTSD controls supports these findings of decreased hippocampal activity. A great deal of psychophysiological assessment evidence indicates that stimulus presentation to PTSD sufferers of sights, sounds, and smells associated with the long-past traumatic event will immediately send the neuroendocrine system into overdrive and cause physiological responses such as increased heart rate, blood pressure, and triglyceride and cholesterol levels, along with decreased blood flow to the skin and gastrointestinal and renal areas. These psychophysiological responses are not evinced in control subjects who are presented with the same stimuli (Lating & Everly, 1995).
Affective-State-Dependent Retention
There is now very clear evidence that physiological changes occur in the presence of trauma (Briere & Scott, 2006; Friedman, 2015) and are exacerbated when the trauma becomes ongoing and complex (Ford, 2009). Changed physiological functioning due to traumatic stimuli is important as a building block in Bower’s (1981) hypothesis of affective-state- dependent retention. Bower has proposed that because the traumatic event was stored in memory under completely different physiological (increased heart rate, higher adrenal output) and psychological (ex- treme fright, shock) circumstances, different mood states markedly interfere with recollecting specific cues of the event. Karl, Malta, and Maercker’s (2006) meta-analysis supports the hypothesis that changes in memory processing accompany PTSD. Therefore, the important elements of the memory that need ex- posure in order to reduce anxiety are not accessible in the unaroused state (Keane et al., 1985, p. 266) and can be remembered only when that approximate state of arousal is reintroduced by cues in the environment (Keane, 1976). Indeed, there is evidence that release of neuromodulators such as norepinephrine when an individual is in a stressful situation leads to patho- logical response to recall of previous traumatic events for which the individual has no previous memory (Bremner et al., 1995). To the contrary, the classic dissociative, numbing response and “forgetting” of the traumatic event may be caused by excessive endogenous opioids secreted during prolonged stress (van der Kolk, 1996a, p. 227). Thus the notion that a victim of PTSD can “just forget” or adopt a “better, more positive attitude” does little to effect change in the individual (Keane et al., 1985, p. 266). This proposal has important implications for treatment, particularly with respect to returning the person to as close an approximation of the event as possible. These neurological issues are even more ominously true for children
