Posttraumatic Stress Disorder (PTSD)

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By Persis Mary Hamilton, RN, CNS, MS, EdD

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Explain the relationship of trauma, stress, memory, and emotions to PTSD.
• Identify medical and nursing diagnostic features of PTSD.
• Evaluate the principle outcome goals of PTSD treatment.
• Discuss therapeutic approaches for achieving outcome goals.

AN ANCIENT MALADY

History is replete with accounts of individuals who have experienced or witnessed terrifying events; felt intense fear, helplessness, and horror; and suffered ongoing emotional distress.

• One of the oldest records of such psychological torment was found in Egypt, circa 1900 B.C.E., where a physician described a peculiar response to earlier trauma (Veith, 1965).
• In 1606 A.D., Shakespeare portrayed the gruesome dreams, mental anguish, and hallucinations of Macbeth and his wife after the bloody murder of Duncan, King of Scotland.
• In 1864, John Erichsen published a medical study of people who had survived railway crashes and thereafter developed “railway spine,” an ongoing fear of speeding trains (Trimble, 1981).
• Following the Civil War (1861–1865), veterans who had developed emotional distress were diagnosed as having “soldier’s heart” (Lamprecht & Sack, 2002).
• In 1901, a physician described a man who survived an industrial explosion and thereafter suffered “traumatic reminiscences” (Lamprecht & Sack, 2002).
• After World War I (1914–1918), veterans with ongoing emotional distress were said to suffer “shell shock”; following World War II (1939–1945), such distress was described as “battle” or “combat” fatigue (Jones, 2005).
• In 1956, Hans Selye wrote The Stress of Life, in which he described how stressors such as extreme fear disrupt the normal balance of life in a process he called the general adaptation syndrome (GAS).
• Between 1959 and 1973, in the jungles of Vietnam, Laos, and Cambodia, U.S. soldiers fought a terrifying guerilla war in which 58,200 died and thousands suffered injuries. Ongoing psychological distress was common, but veterans had difficulty obtaining disability benefits because there was no accepted psychiatric diagnosis for such emotional and behavioral anguish (Jones, 2005).
• In 1980, in the third edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the American Psychiatric Association (APA) classified posttraumatic stress disorder (PTSD) as one of several anxiety disorders. In 1994 the APA further refined criteria for PTSD in DSM-IV, and in 2000 it reaffirmed those criteria in the Textural Revision (DSM-IV-TR).
• In 1989, because of a recognized need, the National Center for Posttraumatic Stress Disorder was established within the U.S. Department of Veterans Affairs. Its mission was and is “to advance the clinical care and social welfare of America’s Veterans through research, education, and training in the science, diagnosis, and treatment of PTSD and stress-related disorders” (National Center for PTSD, 2011).
• Beginning in 2001 in Afghanistan and 2003 in Iraq, military action brought increased evidence of the long-term effects of urban warfare and of other terrifying events upon the human psyche. As a result, posttraumatic stress disorder (PTSD) has become the focus of intensive scientific study.

UNDERLYING CONCEPTS

Even though PTSD has been described throughout human history, veterans groups and healthcare providers have been slow to acknowledge its existence or explore its dimensions. This reticence may have been due to the sigma of cowardice and weakness, or perhaps to the variability of symptoms. For whatever the reason, the disorder has been ill defined and its treatment inconsistent.

Recently, scientists have begun to understand that people respond to terrifying events in different ways, intensities, and time frames. This response varies, not because of faint-heartedness or mental illness, but because of the complexity of the human brain as it adapts to internal and external stressors. Several complex factors are involved, namely trauma, stress and stressors, memory, and emotions.

Trauma

Trauma is the direct personal experience of an event that involves actual or threatened death or serious injury to one’s physical integrity (APA, 2000). Trauma can alter the very foundations of a person’s life and cause profound emptiness, loss of hope, trust, or caring for oneself or others. It can produce all manner of disorders, including depression, anxiety, somatoform disorders, substance abuse, psychosis, and personality disorders.

TYPES OF TRAUMA

There are two primary categories of traumatic events: widespread devastation and interpersonal terror.

Widespread Disasters

Widespread devastation affects many people all at the same time. These calamities include natural disasters such as earthquakes, hurricanes, and tsunamis; large-scale transportation accidents; explosions and fire; motor vehicle accidents; life-threatening epidemics; and radiation, terrorist attacks, and wars.

• Natural disasters. These are environmental events that adversely affect a significant number of people and include earthquakes, floods, hurricanes, tornados, and tsunamis. Fearing for ones life or witnessing the injury or death of others is the traumatizing aspect of these events.
• Mass violence. These are vicious attacks on people by people, such as the systematic genocide of European Jews in Nazi death camps before and during World War II and the genocide of non-Arab peoples in the Darfur region of Sudan by Sudanese and Janjaweed militia.
• Large-scale transportation accidents. These include such tragedies as train derailments, airline crashes, shipwrecks, and auto accidents with multiple victims, high fatality rates, serious injuries, and long delays of rescue.
• Explosions and fires. These may be caused by gas explosions, regional firestorms, and careless use of candles, cigarettes, and matches. Fires are especially traumatic because they often cause serious injuries requiring reconstructive surgeries, long recovery periods, and ongoing pain and suffering.
• Motor vehicle accidents. About 20% of individuals in the United States experience one or more serious motor vehicle accident (Briere & Scott, 2007). Many victims go on to develop significant psychological distress, especially if the accident caused major injury or death. Grief and self-blame magnify the psychological aftermath of such events, and survivors may sustain traumatic brain injury, further complicating recovery.
• Life-threatening epidemics and radiation. Widespread infectious diseases and radiation are considered traumatic events when the diagnosis and treatment are accompanied by ongoing fear, further injury, threat of imminent death, and possibility of a prolonged recovery time.
• Terrorist attacks and war. Terrorist attacks and war involve a wide range of violent and traumatic experiences that cause injury or death.

Interpersonal Terror

Interpersonal terror includes such things as torture, rape, sexual assault, partner battery, stranger physical assault, kidnap/hostage prey, and child abuse—either as victim or witness.

• Torture. Torture has been defined by the United Nations as “an act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining information or confession and punishing or intimidating the person or a third person” (Vesti & Kastrup, 1995). Methods of torture include beatings, sleep deprivation, electric shock, burning, near strangulation, drowning, crushing, breaking bones, being forced to engage in humiliating acts, sensory deprivation, and threats of death or mutilation. Victims of torture are at high risk for PTSD.
• Rape and sexual assault. Rape is nonconsensual oral, anal, or vaginal sexual penetration of the victim, made possible with threats, physical force, or incapacitating drugs. Sexual assault usually refers to any forced sexual contact short of rape. In the United States, 14% to 20% of women and 2% to 4% of men report having been raped. Rape and sexual assault are risk factors for PTSD (Tjaden & Thoennes, 2000).
• Partner battery (spousal abuse, domestic violence). Partner battery is the physical or sexual assault by one adult of another in an intimate, sexual, and often cohabiting relationship. An amazing one fourth of individuals in the United States who live with a partner report at least one incident of physical aggression such as punching, kicking, or choking (Straus & Gelles, 1990).
• Stranger physical assault. Stranger assaults are violent acts such as beatings, stabbings, and attempted strangulation by a person who is not well known to the victim. The motive may be robbery or territorial dominance by a gang. Hence, more men than women suffer stranger physical assault. In one study, 64% of men who sought care in an inner-city emergency department went for help because of a physical assault (Currier & Briere, 2000).
• Kidnap or hostage prey. This is an especially traumatic event because hostages are in immediate threat of injury and death and are helpless to defend themselves. They may be held for hours, days, or even years and physically restrained, assaulted, and deprived of water and food. Whether hostages are alone or within a group, or whether they know their captor or not, they are at high risk for PTSD.
• Child abuse. Child abuse includes physical, sexual, and psychological violence, ranging from severe spankings to life-threatening beatings, fondling/rape, neglect, and abandonment. Trauma of this kind leaves its victims with major psychological scars and with a greater likelihood of being sexually or physically victimized later in life. Even when childhood sexual abuse does not involve violence or physical injury, it is classified as a traumatic event (Classen et al., 2005).
• Revictimization. Tragically, victims of interpersonal traumas such as child abuse, partner battery, sexual assault, and rape are at a statistically greater risk for further interpersonal trauma and victimization. Later traumas may lead to additional behaviors and responses that become risk factors for further trauma and complex mental health problems. This mix of multiple traumas and complicated symptomatic responses is well known to trauma-focused clinicians, who may find it difficult to trace certain symptoms to specific traumas (Briere & Scott, 2007).

RISK AND RESILIENCE

People respond to trauma in remarkably different ways. When a group of unrelated individuals is exposed to the same traumatic event, one person may develop a full-blown stress disorder lasting for months or years, one may become depressed and suicidal, and another may experience only mild, transient symptoms. Researchers identify such variation of symptoms as risk factors and resilience factors for traumatic distress.

Risk Factors

The presence of any risk factors makes people more vulnerable and more likely to develop severe symptoms. Risk factors fall into at least three categories: (1) variables specific to the victim, (2) characteristics of the trauma, and (3) social response, support, and resources available to the victim after the event.

• Victim variables. People who are more likely to develop posttraumatic symptoms are women, younger or older adults, African-Americans and Hispanics, people of lower socioeconomic status, those with prior psychological disorders, individuals with dysfunctional coping styles, people who have previous exposure to trauma, persons with a genetic predisposition, and individuals who express extreme distress during or just after a trauma (Briere & Scott. 2007).
• Characteristic of trauma. Posttraumatic symptoms are more common when the trauma is an intentional act of violence, produces physical as well as psychic harm, goes on for long periods of time, causes grotesque injury and death, involves sexual assault or rape, brings about the loss of a close friend or relative, and occurs suddenly without warning (Briere & Scott, 2007).
• Social response, support, and resources. The symptoms and intensity of posttraumatic stress are reduced when family, friends, healthcare providers, and aid agencies provide social support and resources after a traumatic event, including their presence, acceptance, nurturance, tangible assistance, and nonjudgmental empathy, no matter what the trauma.

Resilience Factors

As more is learned about PTSD, leaders in traumatic high-risk occupations are beginning to pay attention to the need for resilience in those who carry out the duties of their occupation. These include such professions as firefighters, emergency care providers, and police and military officers. The National Institute of Mental Health (2011) has suggested five specific actions and personal characteristics that increase resistance to PTSD, as follows:

• Seek support from other people, such as friends and family
• Find a support group after a traumatic event
• Feel good about one’s own actions in the face of danger
• Possess coping strategies to survive the traumatic event and learn from it
• Despite feelings of fear, act and respond effectively

Stress and Stressors

The concept of stress began with the pioneering work of Walter Cannon (1871–1945). He investigated the sympathetic nervous system as it reacts to threat and noticed that the body responds in a predictable sequence. Hans Selye (1991) carried on the work of Cannon, defining stress as the “rate of wear and tear on the body” and stressors as “causative agents of stress.” He found that stressors might be physical (such as extreme cold, infection, injury, and pain) or psychological (such as fear, sadness, anger, and disgust). He identified what he called a general adaptation syndrome (GAS) whereby the body maintains homeostasis, or balance (see box).

Memory

Memory is the retention of and ability to recall information, personal experiences, and procedures. It comprises a diverse set of cognitive capacities by which we retain information and reconstruct past experiences (Stanford Encyclopedia, 2010). Although the structure and function of the brain has been studied extensively, there is still no universal agreement about just how memory works. However, research-supported evidence tells us that:

• Memory is a set of encoded neural connections that pass through various parts of the brain.
• The stronger the neural connection, the stronger the memory; the more traumatic an event, the more likely it will be remembered.
• Recollections of an event can occur by a stimulus to any of the parts of the brain where there is a neural connection for its memory.
• If the brain is healthy and people are fully conscious when they experience a traumatic event, the likelihood that they will forget the event is nearly zero, unless they are very young or the brain is injured.
• Thinking and talking about an experience creates strong encoding by a process called consolidation. Such encoding enhances the chances of remembering the experience.
• There are distinct types and elements of memory involving different parts of the brain. For example, the hippocampus stores ongoing incidents (short-term working memory); the amygdala stores emotional memories, mainly negative ones; the prefrontal cortex is involved in the consolidation of long-term memories; the cerebellum, though associated with motor coordination skills, may also be involved in remembering strong emotions, especially in the consolidation of long-term fearful memories.
• Memories are lost because they were never elaborately encoded. Perception is mostly a filtering and consolidation (defragmenting) process. Interests and needs affect perception, but most of what is available to remember will never be processed and what is processed will be forgotten (Capital Research Limited, 2009).
• Amnesia (forgetting) is not unusual. It is the standard condition of the human species. We do not forget simply to avoid being reminded of unpleasant things. We forget either because we did not perceive closely in the first place or because we did not encode the experience in the parietal lobes of the cortical surface (short-term memory) or in the prefrontal lobe (long-term memory), a process that requires elaborate encoding (Carroll, 2010).
• Emotions act on memory at all points of the memory cycle: perceiving, encoding (consolidating), and retrieval (Erk, 2010).

Emotions

Emotions play an important role in the memory of traumatic events. For this reason, caregivers of those who suffer from PTSD need to understand just what emotions are, how they are experienced, and what purpose they serve in the survival of human beings.

An emotion is “a complex sequence of events having elements of cognitive appraisal, feelings, impulses to action, and overt behavior; it is a feeling that accompanies an adaptive behavior for survival” (Plutchik, 1991).

PRIMARY EMOTIONS

Studies of the emotions have identified four positive and four negative emotions relative to the pleasure or displeasure they bring.

EMOTIONS

	Primary Emotions	Degrees of Feeling	Life-Preserving Functions
Source: Adapted from Plutchik, 1991.
Positive	Acceptance (love)	Adoration-acceptance-toleration	Incorporation
	Anticipation (hope)	Vigilance-anticipation-hope	Exploration
	Surprise (shock)	Amazement-surprise-distraction	Orientation
	Joy (happiness)	Ecstasy-joy-pleasure	Reproduction
Negative	Fear (terror)	Terror-fear-apprehension	Protection
	Anger (wrath)	Rage-anger-annoyance	Destruction
	Disgust (revulsion)	Loathing-disgust-boredom	Rejection
	Sadness (sorrow)	Grief-sadness-pensiveness	Reintegration

Each emotion has varying degrees of intensity and may combine with other emotions to form more complex emotions, such as to jealousy (sadness, anger, fear) and optimism (joy and anticipation).

Emotions serve life-preserving functions for the survival of the human species, including: incorporation of what is helpful, exploration of the environment, orientation for the sake of safety, reproduction for continuation of the species, protection against harm, destruction of danger, rejection of what may be harmful, and reintegration to wholeness when wounded.

Though emotions may be called positive or negative, in themselves they are neither good nor bad. However, the actions people take when they experience an emotion can be harmful or helpful to others or themselves. For example:

• Unmodulated joy may become mania.
• Uncontrolled anger may beget violence and cruelty.
• Unresolved sadness may lead to depression and suicide.
• Unfocused or inappropriate fear may become anxiety, phobia, and paranoia.

FEAR AND ANXIETY

Fear is a normal, protective response to a specific danger, such as an attack by an armed assailant or the sight of a black widow spider. When individuals recognize danger (cognition), feel the emotion of fear (feeling), and have an urge to act (impulse), then they take protective action (behavior) either to fight or take flight.

When an event creates an intense experience of the emotion of fear, the event is encoded in memory and acute stress disorder or posttraumatic stress disorder may result.

Anxiety is “free-floating” fear of a nonspecific danger. It creates the same physiological response as fear, yet because individuals do not know who or what is threatening them, they cannot take protective action. As a result, the fear response continues, following the physiological sequence described earlier as General Adaptation Syndrome, and in time individuals become exhausted.

At milder levels, anxiety keeps humans alert and focused, which aids in the work of living. However, when anxiety increases, adaptive behaviors decrease, physical symptoms increase, social adaptation and occupational functioning decline, and anxiety disorders follow. Thus, PTSD is classified as one of the anxiety disorders.

Anxiety Disorders

Plotted in an ascending scale of severity, the continuum of anxiety disorders identified by the American Psychiatric Association (APA) is shown below. Note the relative intensity of posttraumatic stress disorder and acute stress disorder as they relate to other anxiety disorders.

ANXIETY DISORDERS

Source: Adapted from Shoemaker & Varcarolis, 2006.
Mild	Anxiety levels that aid in the tasks of living Psychological factors affecting medical conditions
Moderate	Panic disorder Generalized anxiety disorder Obsessive-compulsive disorder Posttraumatic stress disorder (PTSD) Acute stress disorder
Severe	Somatoform disorders Dissociative disorders Personality disorders
Psychosis	Thought disorders Schizophrenia Cognitive impairment disorders

ASSESSING PTSD

Although there is an increasing awareness of PTSD in servicemen and women returning from combat overseas, it is important to remember that many other individuals may be suffering from the disorder. These survivors may include the diabetic octogenarian in an extended-care facility, a new mother in a postpartum clinic, a non-English-speaking immigrant on dialysis, a high school teacher having a routine physical examination, or a firefighter visiting the emergency department. All patients should be assessed for symptoms of PTSD.

Recognizing Symptoms

Typically, the symptoms of posttraumatic stress disorder fall into three categories: (1) reliving the traumatic event, (2) detachment and avoidance, and (3) exaggerated responses (NCBI, 2010).

Reliving the event to a degree that it interferes with normal life activities:

• Flashbacks during which the event seems to happen again and again
• Recurrent distressing memories of the event
• Repeated dreams of the event
• Physical reactions to situations reminiscent of the event

Detachment and avoidance:

• Emotional “numbing,” feeling that nothing matters
• Disengagement and loss of interest in usual life activities
• Inability to remember important aspects of trauma
• Avoiding places, people, or objects that bring memories of trauma
• Loss of hope

Exaggerated responses:

• Difficulty concentrating
• Exaggerated startle responses
• Hypervigilance and unusual awareness
• Irritability and/or outbursts of anger
• Sleep difficulties

Clinical Interview

The most common method for assessing individuals for PTSD is the clinical interview. In settings such as emergency departments and clinics, the interview focuses on the individual’s immediate safety, emotional stability, and possible exposure to further trauma. The following guidelines may be helpful:

• Establish a level of trust before asking about a specific trauma.
• Explore the person’s reason for asking for clinical services.
• Show empathy as you ask questions.
• Avoid body language or statements that imply disgust or judgment.
• Use behavioral descriptions for clarity, such as “Did someone do something sexual to you that upset you?” rather than “Were you raped?”
• Remember, disclosure of trauma history may cause intense anger, guilt, and shame.
• Pay attention to client reactions to questions, noticing what they do or don’t say as well as what topics they avoid, such as use of mind-altering drugs.
  (Briere & Scott, 2007).

The mnemonic ERRAND may be helpful when assessing for the specific criteria identified by the American Psychiatric Association in the DSM-IV-TR.

ASSESSMENT OF PTSD USING “ERRAND”

Source: Adapted from Kaiman, 2003.
E	Exposure to a traumatic event that occurred more than one month before assessment and involved intense fear, helplessness, or horror and was not merely an “upsetting” event. (If trauma occurred less than four weeks before assessment, diagnosis may be acute stress disorder.)
R	Re-experiencing of a traumatic event in frightening nightmares; restless sleep wit diaphoresis.
R	Reliving or describing the traumatic event causes extreme distress. Various sights and sounds remind survivor of traumatic event. Flashbacks of trauma, with visual, olfactory, tactile, and auditory hallucination.
A	Autonomic hyperarousal with exaggerated startle response. Angry outbursts for little reason, impatience, intolerance of crowds. Hypervigilance, sitting with back to walls, inspecting exits, patrolling at night.
N	Numbing and avoidance. Lack of interest in hobbies or activities. Poor concentration. Emotionally numb, detached, unable to endure strong emotional reactions. Feels hopeless, helpless, and worthless; suicidal ideation. Unable to recall important aspects of trauma. Avoids thoughts of people and places associated with trauma.
D	Duration of symptoms. Acute: one to three months Chronic: three months or more Delayed onset: begin at least six months after trauma

Formal Assessment Tools

Although informal mental status interviews can reveal many posttraumatic stress symptoms, their unstructured nature may overlook important symptoms. For this reason, some clinicians prefer more structured assessment tools.

• Clinician-Administered PTSD Scale (CAPS).This 60-minute comprehensive interview covers all DSM-IV-TR criteria plus the impact of the disorder on occupational and social functioning, symptom severity, guilt, and dissociation (Blake et al., 1995).
• Brief Interview for Posttraumatic Disorder (BIPD). This 20-minute interview is less structured, but it covers all categories of PTSD, acute stress disorder, and brief psychotic disorder. It is less objective than CAPS but takes one third the time (Briere, 1998).
• Acute Stress Disorder Interview (ASDI). This brief tool (15 minutes) is especially useful when the issue is acute stress disorder (ASD) as opposed to PTSD. It evaluates effortful avoidance, dissociative, re-experiencing, and arousal symptoms (Bryant et al., 1998).

Other trauma-specific tests include:

• Posttraumatic Stress Diagnostic Scale
• Davidson Trauma Scale
• Detailed Assessment of Posttraumatic Stress
• Trauma Symptom Inventory
• Trauma Symptom Checklist for Children  

Generic tests include:

• Minnesota Multiphasic Personality Inventory, 2nd ed.
• Millon Clinical Multiaxial Inventory, 3rd ed.
• Symptom Checklist-90-Revised

Physical Examination

Although it may seem obvious to healthcare professionals, people with acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) should have a complete physical examination to check for endocrine, cardiovascular, and neurologic disorders. Furthermore, patients should be asked what over-the-counter drugs and mood-altering substances they are taking (e.g., alcohol, marijuana).

DIAGNOSIS

Medical Diagnosis

A medical diagnosis is the naming of a disorder based on an assessment of physical signs and symptoms, medical history, and results of diagnostic tests and procedures. The box below gives the American Psychiatric Association diagnostic criteria for PTSD. When individuals develop similar symptoms lasting 2 days within 4 weeks of a traumatic event, the diagnosis is acute stress disorder (ASD).

Nursing Diagnosis

Nursing diagnoses are words or phrases that describe an actual or potential human response to health conditions and life processes (NANDA International, 2011).

PLANNING

Planning care involves establishing client-centered goals and expected outcomes, setting priorities, and choosing interventions according to the urgency of each problem. Urgency is measured by client safety, client desires, and nature of the treatment.

Goals and Outcomes

The number one, over-arching goal of treatment for people suffering from PTSD is reintegration, by which the traumatized person metabolizes or internally resolves distressing feelings, thoughts, and memories. This goal influences all therapeutic interventions. The intrinsic function of reliving these experiences appears to be the processing and integrating of disturbing material. This internal working-through activity builds on the innate tendency of humans to process trauma-related memories, adapt to new realities, survive, and even thrive.

From the perspective that posttraumatic stress is adaptive, symptoms such as flashbacks, recurring images, and dreams can be considered “recovery procedures,” not pathological symptoms. Thus, nurses and other clinicians see traumatized individuals not as collections of pathological symptoms but as people who are “at some level attempting to recover, albeit not always successfully” (Biere & Scott, 2007).

The second most important goal of treatment is personal growth. This is not to be interpreted as some platitude about “growing stronger through testing” or “making lemonade from lemons.” It does mean that not all traumatic events are inevitably tragic. Adversity can cause people to develop in ways they never would have imagined, such as acquiring new levels of resilience, greater self-knowledge, additional survival skills, increasing empathy for others, and a broader view of life. At first, people who have suffered great trauma need safety, attention to life support, and help with painful symptoms. Later in the recovery process, personal growth becomes evident (Biere & Scott, 2007).

TREATMENT

Basic Principles

To achieve reintegration and personal growth—the primary goals of treatment for traumatized individuals—clinicians follow these basic principles:

• Respect and positive regard for survivors of trauma
• Hope and expectation of recovery
• Safety from further trauma
• Physical and emotional stability
• Consistent therapeutic relationships with caregivers
• Individualized treatment plans that are sensitive to gender and sociocultural issues, supported by every member of the treatment team, evaluated continually, and revised appropriately
  (Foa et al., 2000).

Elements of Treatment

A review of existing literature suggests that, regardless of the theoretical stance of therapists, effective treatment for PTSD includes: (1) provision of a healing environment; (2) education about trauma; (3) distress reduction and emotion regulation; (4) cognitive interventions; (5) emotional processing; (6) increasing identity and relational functioning; and (7) psychopharmacology.

HEALING ENVIRONMENT

A healing environment is a place of safety from physical and emotional assault. It is a haven of stability and order with a predictable schedule; adequate food and shelter; and an environment of human kindness, respect, and safety. It is a place where survivors of trauma receive unconditional positive regard, nonpossessive warmth, genuineness, and accurate empathy (Rogers, 1961; Carkhoff, 1977). In such a sanctuary, a consistent, therapeutic relationship is established where every individual is respected and taken seriously. Survivors are commended for the strength and courage they demonstrate by their mere presence and willingness to confront painful memories.

EDUCATION ABOUT TRAUMA

Education about trauma and its symptoms greatly facilitates healing. It not only gives survivors information about the nature of trauma and its effects, but it also validates their experience and helps them integrate relevant information into their overall perspective. Education about trauma is especially valuable for victims of interpersonal violence because their reality may have been distorted by their abusers, making them believe they deserved the abuse and are to blame for its consequences. Education for survivors of trauma focuses on the following topics:

• The prevalence of trauma
• Common myths associated with the trauma
• Usual reasons why perpetrators engage in interpersonal violence
• Typical immediate responses to trauma
• Lasting posttraumatic responses to victimization
• Trauma processing and reframing symptoms
• Safety planning for at-risk victims

When education is imbedded in the therapeutic context, it becomes more relevant and better integrated into the understanding of survivors. In addition to planned education from clinicians, survivors learn from fellow members of a support group and from well-chosen, timely handouts and self-help books. Regardless of the source, all educational material should be monitored and evaluated for:

• Accuracy and quality, making sure the information does not blame the victim or advocate from some social or religious perspective
• Language that fits individual reading and comprehension levels
• Cultural suitability that is free of prejudicial views of race, sexual orientation, gender, and customs
• Appropriateness for the stage of healing of survivors

(Sources of handouts and books are listed in the “Resources” section below.)

DISTRESS REDUCTION AND EMOTION REGULATION

Survivors of trauma often suffer chronic levels of anxiety and arousal and strong negative emotional responses to trauma-related memories. Such memories are easily triggered and difficult to manage. Because these feelings are so vivid and painful, survivors may rely on avoidance strategies, including substance abuse, dissociation, and unhealthy tension-reducing behaviors (such as binge eating, promiscuous sex, and self-mutilation).

Avoidance measures hinder recovery and may cause survivors to drop out of therapy and give up. To help people cope with distress and increase their capacity to regulate negative emotions, clinicians use and teach stress-reduction activities, including grounding, breathing-relaxation exercises, and emotional regulation.

Grounding

In therapy sessions, when clients experience sudden panic, flashbacks, intrusive negative thoughts, dissociative states, or psychotic symptoms, the therapist may use a technique called grounding. At these times the clinician changes the subject from whatever was being discussed to the immediate therapeutic process. To reduce such overwhelming distress, the therapist may lead the person in breathing or other relaxation exercises, or just sit quietly, acknowledging their pain. Grounding should be used judiciously to avoid implying that something has gone wrong.

Breathing-Relaxation Exercises

Slow, deep breathing lowers tension and leads to inadvertent muscle relaxation. When trauma survivors learn how to breathe deeply and relax, they have a tool they can use at any time and in almost any place. Such knowledge is empowering. Many therapists begin each session with breathing or relaxation exercises to foster a sense of control and safety in survivors.

Emotion Regulation

In addition to grounding and relaxation, therapists have identified several techniques to help trauma survivors tolerate and reduce negative emotions. These skills include learning to (1) identify and discriminate between emotions, (2) recognize and counter thoughts that trigger intrusive emotions, (3) notice triggers and intervene, and (4) resist harmful tension-reducing behaviors.

• Identify and discriminate between emotions. Many survivors of trauma have trouble knowing exactly what they are feeling beyond a sense of feeling “bad” or “upset.” In addition, some individuals have difficulty differentiating anger from fear, disgust, or sadness. For example, survivors may not be able to say, “I feel fearful,” let alone say, “I feel fearful because I feel threatened by. . . .” Therapists can help survivors in this area by regularly discussing the emotional experiences of clients.
• Recognize and counter thoughts that trigger intrusive emotions. Not only do survivors need to identify feelings, they need to identify thoughts, especially thoughts that trigger strong emotional reactions. By becoming aware of triggering thoughts, survivors can lessen their impact by explicitly countering a thought, for example, “Nobody is out to get me.” As survivors become able to identify such ideas, place them in a realistic context, and counter them with positive thoughts, they develop the capacity to prevent and regulate intrusive emotions (Biere & Scott, 2007).
• Notice triggers and intervene. By identifying triggers in the environment, survivors gain a greater sense of control and safety. They do this by (1) noticing particular thoughts or feelings that are trauma-related; (2) evaluating the specific feature of the thought or feeling that triggers traumatic memory, such as a personal characteristics of their abuser, the sound of a child crying, and the sight of an ambulance; (3) constructing an adaptive strategy, such as taking a “time out,” deep breathing, giving themselves positive self-talk, or using a distraction, such as reading a book.
• Resist harmful tension-relieving behaviors. Often survivors relieve their distress by engaging in harmful tension-reducing behaviors, such as binge eating, promiscuous sex, and self-mutilation. Although it would be best to prevent all such behaviors, in reality, stopping such behavior may be impossible, short of hospitalization. Since avoidance behaviors are survival-based, they are not easily abandoned. However, victims of trauma may be able to delay or reduce the behavior. For instance, a survivor may be able to delay binge eating, tolerate brief periods of discomfort, and eventually overcome the behavior.

COGNITIVE INTERVENTIONS

Survivors of trauma, especially those who have suffered interpersonal violence, are prone to harbor negative beliefs and perceptions about themselves, such as shame and guilt. Cognitive therapy involves reevaluating those beliefs and perceptions and replacing them with more affirming and empowering views. The central goal of cognitive therapy is to assist clients to explore and “think through” their beliefs within the context of when and how those beliefs developed. The process involves talking about a traumatic event and gaining a better understanding of their reasoning.

As they describe a traumatic event chronologically and analytically and place it in a larger context, clients experience an increased sense of perspective and reduced feelings of chaos (Meichenbaum & Fong, 1994). The retelling and the rethinking of a traumatic event somehow provides a degree of closure so that the event does not require further rumination and preoccupation. In this way, survivors develop a coherent narrative(logical story) of the trauma that upset them and are able to incorporate it into their ongoing life.

EMOTIONAL PROCESSING

Emotional processing of traumatic events involves exposure to traumatic memories at the same time the survivor is experiencing safety. Over time, the expectation of treatment is that the extreme fear and horror of the original trauma (the conditioned emotional response) lessens and gradually is extinguished. Eventually, the survivor is able to remember the event without re-experiencing the fear and horror associated with it. Emotional processing is said to follow a five-stage sequence: exposure, activation, disparity, counter-conditioning, and desensitization.

• Exposure. The survivor is exposed to trauma-memory, either as a result of thinking, telling, or being reminded of the trauma from something in the environment.
• Activation. The exposure activates emotional responses that were co-encoded with and conditioned to these memories.
• Disparity. The activated emotional responses of fear and anger are not reinforced in the safety of the therapeutic setting.
• Counter-conditioning. The activated emotional responses of fear and anger are counter-conditioned by opposite emotional experiences as he relives the trauma.
• Desensitization. The counter-conditioning leads to extinction of the original memory-emotion association.

Because exposure of survivors to the horror of a traumatic event can be extremely upsetting, therapists seek to control the intensity of emotions within a therapy session. Ideally, at the beginning of a session survivors are not aroused. In the safety of the therapeutic setting, they may become aroused as they process the traumatic event. As the session draws to a close, the therapist seeks to lower the level of emotionality so that survivors can leave the session in as calm an affective state as possible.

Exposure to traumatic memories may be contraindicated for some survivors, including clients who are severely depressed, extremely anxious, acutely psychotic, or overwhelmed by guilt or shame. Interventions for these clients include the affect regulation and cognitive interventions discussed earlier, psychiatric medication, and hospitalization.

INCREASING IDENTITY AND RELATIONAL FUNCTIONING

Many survivors of multiple traumas have great difficulty with self-identity and interpersonal relationships. This is particularly true of survivors of early and severe childhood trauma who have problems recognizing their own needs and entitlements, maintaining a consistent sense of self, and establishing an internal reference point in times of stress (Allen, 2001). As abused children, they may have concluded that all people are dangerous and that they themselves are intrinsically unacceptable and deserve punishment or disregard. Because of these entrenched problems with personal identity and interpersonal functioning, untreated survivors are more likely to fall victim to multiple abusers, compounding their issues and leading them into further difficulties.

Interventions for survivors with personal identity and interpersonal relationship issues are the same as for all victims of trauma, however a safe and nurturing environment in the presence of beneficent others is especially important. From caring relationships, they are able to gain a sense of personal identity and dignity and learn how to communicate assertively without submission or domination by anyone. Eventually, relating to others no longer triggers the same level of fear, anger, distrust, and avoidant behavior it once did and survivors are able to sustain positive interpersonal relationships.

PSYCHOPHARMACOLOGY

While supportive therapy is of enormous value for sufferers of PTSD, individuals may be so overwhelmed by the disorder they are unable to participate in therapy. In addition, they may suffer from other psychological conditions, such as depression, other anxiety disorders, and psychotic conditions. For this reason, psychotropic medications can be useful adjuncts to trauma-focused therapies, especially in the early phase of treatment.

Several classes of medications are effective in the treatment of anxiety disorders, including antidepressants, anxiolytics, and others. Among the antidepressants, selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment (Simon & Rosenbaum, 2003; National Center for PTSD, 2011). Results of many randomized, double-blind, placebo-controlled studies of SSRIs indicate that these drugs reduce symptoms in the three core symptom clusters of PTSD, namely re-experiencing, hyperarousal, and avoidance. SSRIs are preferable to tricyclic antidepressants because they have more rapid onset of action and fewer side effects. Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the risk of life-threatening hypertensive crisis if clients eat food containing tyramine.

Sufferers of PTSD often self-medicate as a means to avoid or nullify their symptoms, misusing prescribed drugs or self-medicating with alcohol, marijuana, and various herbal preparations. For this reason, PTSD treatment centers advise their clients to refrain from use of nonprescribed substances. When medications are prescribed for clients, clinicians assume the responsibility to monitor both their symptom relief and their overall health status.

MEDICATIONS FOR PTSD

Class	Generic (trade) name	Usual daily dose (mg/day)
Antidepressants
Selective serotonin reuptake inhibitors (SSRI)	Citalopram (Celexa)	10–60 mg
	Duloxetine (Cymbalta)	40-60 mg
	Fluoxetine (Prozac)	10–80 mg
	Fluvoxamine (Luvox)	100–300 mg
	Paroxetine (Paxil)	10–60 mg
	Sertraline (Zoloft)	50–200 mg
Other serotonergic agents	Venlafaxine XR (Effexor XR)	75–225 mg
	Mirtazapine (Remeron)	15–45 mg h.s.
	Trazodone (Desyrel)	150–600 mg
	Bupropion (Wellbutrin)	150–300 mg
Monoamine oxidase inhibitors (MAOIs)	Phenelzine (Nardil)	15–19 mg
	Tranylcypromine (Parnate)	30–60 mg
Tricyclic antidepressants	Amitriptyline (Elavil)	50–300 mg
	Clomipramine (Anafranil)	100–250 mg
	Desipramine (Norpramin)	100–300 mg
	Imipramine (Tofranil)	75–300 mg
	Nortriptyline (Pamelor)	74–150 mg
Anxiolytics
Benzodiazepines	Alprazolam (Xanax)	0.25–2.0 mg
	Chlordiazepoxide (Librium)	15–75 mg
	Diazepam (Valium)	2.5–10 mg
	Lorazepam (Ativan)	0.5–6.0 mg
Nonbenzodiazepine	Buspirone (BuSpar)	30–60 mg

EVALUATION

Identified goals and outcomes serve as a basis for evaluating the effectiveness of interventions for survivors of PTSD. Evaluation questions include:

• Are clients re-experiencing the traumatic event in flashbacks, nightmares, intrusive thoughts, and dissociation? If so, are these experiences less or more frequent?
• Are clients exhibiting hyperarousal symptoms such as restless sleep, muscle tension, irritability, jumpiness, and concentration difficulties? If so, are these symptoms lessening or increasing?
• Are clients using avoidance measures such as binge eating or alcohol abuse to evade thoughts or feelings about their traumatic experience?

PREVENTION

Although natural disasters cannot be prevented, the damage they cause can be anticipated and sometimes mitigated. When such disasters do occur, official and charitable agencies can provide tangible assistance and emotional support.

Some occupations, by their very nature, expose individuals to terrifying traumatic events. These include such dangerous professions as military service, firefighting, underground mining, and deep-sea exploration. To prevent or at least reduce the number of individuals who develop posttraumatic stress disorder, leaders in these professions have begun assessing potential candidates for risk of posttraumatic stress disorder. In addition, they are now providing resilience education for those who are accepted. (See also “Risk and Resilience” above).

As the medical profession becomes aware of the widespread instance of posttraumatic stress disorder in the general population, greater attention will be paid to its prevention and to effective treatment for its victims.