A Therapist-Assisted Internet Self-Help Program for Traumatic Stress.

The authors describe a therapist-assisted, Internet-based self-help intervention to treat posttraumatic stress disorder (PTSD) and discuss how it can be used as an efficient tool to treat large numbers of traumatized individuals. The intervention uses a modified form of stress inoculation training, promoted through daily homework assignments completed in vivo, using fewer therapist resources than standard face-to-face therapy. The process and structure of the treatment program (and structure of the Web site) and clinical and Internet security safeguards are described to introduce practitioners to a unique therapist-assisted self-management model of PTSD. It is hoped that the method described will lead to other novel, efficient methods of delivering interventions and treatment for PTSD in primary care and other outpatient and private practice settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Directed forgetting following mood induction in chronic posttraumatic stress disorder patients.

Current research of posttrauma sequelae suggests that intrusive rather than avoidant-dissociative models more accurately represent the encoding processes of trauma cues. However, posttraumatic stress disorder (PTSD) is often conceptualized as a phasic phenomenon, altering between arousal and avoidance states. The failure to support a relationship between avoidant encoding style and PTSD may reflect this alteration. To explore this hypothesis, participants with PTSD and controls (no PTSD) completed an item-cued directed-forgetting task, following either a dissociative or a serenity (control) mood induction. Results suggested that, following the serenity induction, a standard directed-forgetting effect was observed. However, following the dissociation induction, this effect was not observed. The role of dissociation in impairing encoding via lack of selective rehearsal or source discrimination is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Suicide and bi-modal consciousness.

People are able to experience in (a) a reflective mode of consciousness, in which they are aware of themselves and elements of their environment as objects and (b) a nonreflective mode, in which they experience themselves as at-one with the contents of consciousness. The suicidal individual is seen as identified with the reflective self and alienated by shame and fear from nonreflective being. Nonreflectiveness amounts to the nonexistence of self as an existing object. But the intellect, identified with the object self, confuses the nonreflective extinction of the object self with physical death. To imagine death as an absence of consciousness would seem an impossibility since imagination is an act of consciousness. Hence, the fantasy of death is more likely to be a fantasy of nonresponsiveness to the world of objects. Suicidal thoughts and feelings are viewed as a symbolic expression of the desire to function nonreflectively and the frustration at being unable to do so. E. S. Schneidman's (1965) "depressed, defiant, and dependent dissatisfied" suicidal types are seen as categories of defensive maneuvers against fears of nonreflective functioning. Much cognitive mythology exists which equates nonreflective functioning with irrationality and being out-of-control. Therapists must understand in themselves and validate in the people with whom they work the need for nonreflective functioning. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The body keeps the score: memory and the evolving psychobiology of posttraumatic stress

Ever since people's responses to overwhelming experiences have been systematically explored, researchers have noted that a trauma is stored in somatic memory and expressed as changes in the biological stress response. Intense emotions at the time of the trauma initiate the long-term conditional responses to reminders of the event, which are associated both with chronic alterations in the physiological stress response and with the amnesias and hypermnesias characteristic of posttraumatic stress disorder (PTSD). Continued physiological hyperarousal and altered stress hormone secretion affect the ongoing evaluation of sensory stimuli as well. Although memory is ordinarily an active and constructive process, in PTSD failure of declarative memory may lead to organization of the trauma on a somatosensory level (as visual images or physical sensations) that is relatively impervious to change. The inability of people with PTSD to integrate traumatic experiences and their tendency, instead, to continuously relieve the past are mirrored physiologically and hormonally in the misinterpretation of innocuous stimuli as potential threats. Animal research suggests that intense emotional memories are processed outside of the hippocampally mediated memory system and are difficult to extinguish. Cortical activity can inhibit the expression of these subcortically based emotional memories. The effectiveness of this inhibition depends, in part, on physiological arousal and neurohormonal activity. These formulations have implications for both the psychotherapy and the pharmacotherapy of PTSD.     

Assessment and treatment of posttraumatic stress disorder after a motor vehicle collision: Empirical findings and clinical observations.

Individuals who experience a serious motor vehicle accident (MVA) are at increased risk for psychological problems, particularly posttraumatic stress disorder (PTSD). In this article, we review the literature on PTSD among MVA survivors, with particular attention to available instruments to screen for and assess symptomatology of the disorder. Approaches to the treatment of PTSD in this population are reviewed, separated into interventions designed to prevent PTSD in unselected samples, treatment targeting individuals with acute stress disorder that is designed to prevent subsequent development of PTSD, and therapy for individuals with chronic PTSD. Treatment process issues are discussed in an effort to integrate empirical findings with clinical observations. The empirical literature suggests several approaches to treatment that have good potential outcomes, although continued work is needed to identify factors that predict treatment response as well as augment individual-based treatment formats. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Screening for trauma histories, posttraumatic stress disorders (PTSD) and subthreshold PTSD in psychiatric outpatients.

The ability of the Structured Clinical Interview for DSM-IV (SCID) posttraumatic stress disorder (PTSD) module's screening question to identify individuals with PTSD or subthreshold PTSD was examined. First, the screen's sensitivity for detecting a trauma history was determined. Second, the incremental validity of a more thorough trauma assessment was examined by determining how many individuals responded negatively to the screen but then were diagnosed with PTSD or subthreshold PTSD. Last, the optimal SCID termination point for assessing subthreshold PTSD was determined. Using a trauma list increased the number of participants reporting a trauma; however, the SCID screen captured almost all individuals who had PTSD or subthreshold PTSD. When one screens for subthreshold PTSD, the SCID can be terminated on failure to meet Criterion B. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic stress disorder's frequency and intensity ratings are associated with factor structure differences in military veterans.

We examined possible differences in the factor structure of posttraumatic stress disorder (PTSD) on the basis of whether frequency or intensity symptom response formats were used to assess PTSD. Participants included 669 veterans recruited from an epidemiological study of four Veterans Affairs Medical Centers' primary care clinics in the southeastern United States. Confirmatory factor analysis using measurement invariance testing found that the frequency and intensity symptom formats were significantly different from each other on PTSD's factor structure parameters, including factor loadings, observed variable intercepts, and measurement errors. The only exception was for PTSD's effortful avoidance symptoms, which were associated with equivalent parameter estimates for both the frequency and intensity formats. Implications for the clinical assessment of PTSD and interpretation of the extant literature base on PTSD's factor structure are considered. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Recognizing Defenses in the Drawings and Play of Children in Therapy.

Children's drawings and play have long been recognized as rich repositories of symbolic material derivative of infantile sexual fantasy. That view is based predominantly on the early drive theory approach to the interpretation of dreams with an almost exclusive focus on symbolic content. In an effort to broaden the interpretive skills available to the child therapist, this article places the content of children's drawings and play into the background and brings the defensive processes into higher relief. It addresses the defenses in children's play and even more so the defenses in children's drawings. Without creating a simplistic formula, the author offers examples of ways to recognize defenses in children's drawings and play based on observations from clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The latent structure of posttraumatic stress disorder: A taxometric investigation of reactions to extreme stress.

Mental health professionals have debated whether posttraumatic stress disorder (PTSD) can be qualitatively distinguished from normal reactions to traumatic events. This debate has been fueled by indications that many trauma-exposed individuals evidence partial presentations of PTSD that are associated with significant impairment and help-seeking behavior. The authors examined the latent structure of PTSD in a large sample of male combat veterans. Three taxometric procedures--MAMBAC, MAXEIG, and L-Mode--were performed with 3 indicator sets drawn from a clinical interview and a self-report measure of PTSD. Results across procedures, consistency tests, and analysis of simulated comparison data all converged on a dimensional solution, suggesting that PTSD reflects the upper end of a stress-response continuum rather than a discrete clinical syndrome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neuropsychological functioning in posttraumatic stress disorder and alcohol abuse.

Studies have shown differences in neuropsychological functioning between groups with posttraumatic stress disorder (PTSD) and control participants. Because individuals with PTSD often have a history of comorbid alcohol abuse, the extent to which an alcohol confound is responsible for these differences remains a concern. The current study compares neuropsychological testing scores in 4 groups of veterans with and without PTSD (PTSD+ and PTSD-, respectively) and with and without a history of alcohol abuse (ETOH+ and ETOH-, respectively): n for PTSD+/ETOH- = 30, n for PTSD+/ETOH- = 37, n for PTSD-/ETOH+ = 30, and n for PTSD-/ETOH- = 31. Results showed that PTSD, when alcohol, educational level, vocabulary, and depression are controlled for, was associated with decreased verbal memory, attention, and processing speed performance. Alcohol abuse history was associated with decreased visual memory performance. By controlling for alcohol and depression, the authors can more conclusively demonstrate that verbal memory and attention differences are associated with PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparison of immediate-onset and delayed-onset posttraumatic stress disorder in military veterans.

Differences in symptoms, trauma exposure, dissociative and emotional reactions to trauma, and subsequent life stress in war veterans reporting immediate-onset or delayed-onset posttraumatic stress disorder (PTSD) or no PTSD were investigated. The role of life stress in delayed-onset PTSD was also studied. Retrospective interviews were conducted with 142 United Kingdom veterans receiving a war pension for PTSD or physical disability. Immediate-onset and delayed-onset PTSD were similar in the number and type of symptoms reported at onset, but the delayed-onset group differed in showing a gradual accumulation of symptoms that began earlier and continued throughout their military career. They were more likely to report major depressive disorder and alcohol abuse prior to PTSD onset. Both groups described similar amounts of trauma exposure, but those in the delayed-onset group reported significantly less peritraumatic dissociation, anger, and shame. Veterans with delayed onsets were more likely than veterans with no PTSD to report the presence of a severe life stressor in the year before onset. In conclusion, the results suggest that delayed onsets involve a more general stress sensitivity and a progressive failure to adapt to continued stress exposure. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic stress disorder: Silent problem among older combat veterans.

Examines posttraumatic stress disorder (PTSD) among older Vietnam combat veterans. It is suggested that PTSD among these veterans is generally chronic, silent, and exacerbated by the problems of aging. These Ss with PTSD can be divided into those with full PTSD and those with partial PTSD. Studies are cited showing prevalence rates for PTSD. The difficulties in measuring PTSD are described. Several moderating variables influence the expression of trauma problems at later life, including the presence of other stressors, health status, social support, and comorbidity. Several forms of therapy are considered, including cognitive behavioral therapy, reminiscence, and relaxational desensitization. Also, several treatment suggestions are given, advocating interventions of a stuck narrative in an aging population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of suppressing trauma-related thoughts on women with rape-related posttraumatic stress disorder

A hallmark symptom of posttraumatic stress disorder (PTSD) is the presence of intrusive thoughts that come to mind against an individual's will and are frequently accompanied by considerable distress. This investigation examined the effects of deliberate suppression of rape-related thoughts on female sexual assault survivors, in order to explore this facet of PTSD. Seventeen women with chronic PTSD following a sexual assault were contrasted with nineteen survivors without PTSD, using a thought suppression paradigm (e.g. [Wegner, Schneider, Carter, & White (1987) Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53 5-13]). Results indicated that PTSD participants experienced a rebound in the frequency of rape-related thoughts following deliberate suppression, whereas non-PTSD participants did not experience a rebound. Reported level of perceived controllability over rape-related thoughts for the PTSD participants was significantly lower during the suppression phase (as compared with the expression phase) relative to the non-PTSD participants. PTSD participants were significantly more anxious, depressed and distressed throughout the procedure relative to non-PTSD participants, although mood changes did not parallel the rebound effect found with rape-related thoughts in the PTSD group. Results are discussed in light of the role that intrusive thoughts may play in the maintenance of PTSD.     

Assessing posttraumatic stress disorder with or without reference to a single, worst traumatic event: Examining differences in factor structure.

The authors examined the effects of a methodological manipulation on the Posttraumatic Stress Disorder (PTSD) Checklist’s factor structure: specifically, whether respondents were instructed to reference a single worst traumatic event when rating PTSD symptoms. Nonclinical, trauma-exposed participants were randomly assigned to 1 of 2 PTSD assessment conditions: referencing PTSD symptoms to their worst trauma (trauma-specific group, n = 218) or to their overall trauma history in general (trauma-general group, n = 234). A 3rd group of non-trauma-exposed participants (n = 464) rated PTSD symptoms globally from any stressful event. Using confirmatory factor analysis, the authors show that the 4-factor PTSD model proposed by D. W. King, G. A. Leskin, L. A. King, and F. W. Weathers (1998; separating effortful avoidance and emotional numbing) demonstrated the best model fit for trauma-general and non-trauma-exposed participants. The 4-factor PTSD model proposed by L. J. Simms, D. Watson, and B. N. Doebbeling (2002; emphasizing a general dysphoria factor) demonstrated the best model fit for trauma-specific participants. Measurement invariance testing revealed that non-trauma-exposed participants were different from both trauma-exposed groups on factor structure parameters, but trauma groups were not substantially different from each other. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The structure of PTSD among two cohorts of returning soldiers: Before, during, and following deployment to Iraq.

Evidence suggests either a four-factor emotional numbing or dysphoria model likely reflects the underlying structure of posttraumatic stress disorder (PTSD). Questions remain as to which of these structures best represents PTSD, how the structure changes with time, the applicability of models to returning veterans, and the validity of the symptom clusters. The present study addresses these questions among two longitudinal samples of National Guard soldiers assessed prior to, during, and following a combat deployment to Iraq. Findings support a four-factor intercorrelated dysphoria model of PTSD that remains stable across samples and time points. Differential associations were observed among PTSD symptom clusters over time and between symptom clusters and both depression and combat exposure, supporting important distinctions between symptom clusters. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Post-traumatic stress disorder. New research findings

This article reviews recent research results on posttraumatic stress disorder (PTSD). Epidemiological studies show that PTSD is a common disorder within the normal population with a high degree of chronic courses. Degree of severity as well as dissociative symptoms during the traumatic event seem to have an impact on course and outcome of PTSD. A genetic disposition, familial psychopathology and premorbid personality traits as background variables seem to have an influence on the development of PTSD whereas coping strategies, as well as social support, modify the course of the disease. The investigation of biological parameters refers to the hypothalamic-pituitary-adrenal-axis system, provocation studies, psychophysiological studies, and studies of the endogenous opiate system. In regard to therapy studies only those with a randomised allocation to two different therapies as well as with a control group without therapy or a waiting list group are considered, using the DSM-III or DSM-III-R diagnostic criteria for PtSD. Five pharmacological studies could show a positive effect by antidepressants. Six behaviour therapy studies (two systematic desensitisation and four flioding) produced an improvement of PTSD symptomatology. The pathogenetic models discussed here are memory imprinting, kindling, dysregulation of the opioid neuromodulation, classical conditioning and disturbed cognitive schemas, which reflect as single models only a facet of the pathogenesis.     

Contrasting exposure and experiential therapies for complex posttraumatic stress disorder.

In this paper, the authors compare and contrast two psychotherapy paradigms for the treatment of complex posttraumatic stress disorder (PTSD): a behavioral therapy (prolonged exposure; PE) and an experiential therapy (Accelerated Experiential Dynamic Psychotherapy; AEDP). PE has received strong research support as an effective treatment for PTSD. The scientific evidence for experiential therapy is sparser, but also positive. In addition, clinical and research evidence suggest that (a) experiential processes are inherently embedded in PE, and may influence PE outcomes; and that (b) AEDP addresses several clinical and relational factors that are negative prognostic factors for PE (e.g., affect dysregulation, disorganized attachment, sense of alienation and mental defeat, dissociation, and disorders of the self). Suggestions are provided for further empirical exploration of the process and efficacy of AEDP and experientially informed PE for complex cases of PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)