Microsoft word - approaches to the treatment of ptsd - van der kolk

Approaches to the Treatment of PTSD
Introduction
Terrifying experiences that rupture people's sense of predictability and invulnerabilitycan profoundly alter the ways that they subsequently deal with their emotions and withtheir environment. The syndrome of Post Traumatic Stress Disorder (PTSD) can followsuch widely different stressors as war trauma, physical and sexual assaults, accidents,and other natural and man-made disasters. Mirroring the confusion and disbelief ofpeople whose basic assumptions are shattered by traumatic experiences, the psychiatricprofession periodically has been fascinated by trauma, followed by sudden disbelief inthe importance of trauma in the genesis of psychopathlogy. Over the past decade ourprofession has experienced the third intense wave of efforts to grasp the reality of traumaon body and soul, after the first at the Salpetriere during the closing decades of the 19thcentury, and the second, spearheaded by Abram Kardiner (1941), in the 1940s. Thefindings about the consequences of trauma and what constitutes effective treatment havebeen extraordinarily consistent over these 120 years.
Several studies in recent years have shown that Post Traumatic Stress Disorder (PTSD)is among the most common of psychiatric disorders. The National Vietnam VeteransReadjustment Study (Kulka et al,1990) found that approximately twenty years after theend of the Vietnam war 15.2% of Vietnam theater veterans continued to suffer fromPTSD. However, PTSD is not confined to combat soldiers, but is quite common in thegeneral population, particularly among psychiatric patients. Various studies havedemonstrated a life time prevalence of between 1.3% (Heizer et al,1987) and 9%(Breslau & Davis, 1991) in the general population and at least 15% in psychiatricinpatients (Saxe et al.,1993). Although PTSD is associated with high levels of chronicity,co-morbidity and functional impairment, the general level of functioning varies a greatdeal between affected individuals.
Lack of predictability and controllability are the central issues for the development andmaintenance of PTSD. The combination of intrusive and numbing symptoms has beenconsistently noted over the past century (e.g. Janet, 1904; Kardiner,1941), and forms thebasis of our understanding of the nature of PTSD. What distinguishes people whodevelop posttraumatic stress disorder (PTSD) from people who are merely temporarilyoverwhelmed is that people who develop PTSD become "stuck" on the trauma, keep re-living it in thoughts, feelings, or images. Evidence during the past decade supports thenotion it is the intrusive reliving, rather than the traumatic event itself that is responsiblefor the complex biobehavioral change that we call PTSD (McFarlane,1988). Once theybecome dominated by intrusions of the trauma, traumatized individuals begin organizingtheir lives around avoiding having them (van der Kolk & Ducey, 1984). Avoidance maytake many different forms: keeping away from reminders, ingesting drugs or alcohol that numb awareness of distressing emotional states, or utilizing dissociating to keepunpleasant experiences from conscious awareness. The helplessness, conditionedhyperarousal, and other trauma-related changes may permanently change how a persondeals with stress, alter his/her self-concept and interfere with the view of the world as abasically safe and predictable place.
A relative sense of safety and predictability are preconditions for effective planning andpersonal action. Freud (1911/1959) described how, in orderto function properly, peopleneed to be able to define their needs, anticipate how to meet them and plan forappropriate action. In order to do this, people need to be able to mentally entertain arange of options, without resorting to action. He called this capacity: "thought asexperimental action" . Traumatized people seem to lose this essential capacity and havedifficulty turning inwards to utilize their emotions as guides for action (van der Kolk &Ducey,1984). Instead, their internal world becomes a danger zone and they seem tospend their energies on NOT thinking and planning.
The therapeutic relationship with these patients tends to be extraordinarily complex. Itconfronts all participants with intense emotional experiences, forcing them to explore thedarkest corners of the mind, and to face the entire spectrum of human glory anddegradation. The devastating effects of trauma on affect modulation, attention,perception, and the giving and taking of pleasure bring us face to face with the fulldestructive impact of traumatic stress to dominate, use and control others.
The role of memory and dissociation
Pierre Janet (1889) first described how the central issue in trauma is dissociation:memories of what has happened cannot be integrated into one's general experientialschemes and ore split off from the rest of personal experience. Physiologicalhyperarousal seems to be a central precondition for dissociation to occur (Rauch et al,1995). Lack of integration on a schematic level causes the experience to be stored asaffect states or as somatosensory elements of the trauma (van der Kolk & Fisler, in press1995), which return into consciousness when reminders activate customary responsepatterns: physical sensations (such as panic attacks), visual images (such as flashbacksand nightmares), obsessive ruminations, or behavioral reenactments of elements of thetrauma.
Most studies of people who develop PTSD find significant dissociative symptomatology(Bremner, 1993; Marmar, 1994) The most extreme form of post-traumatic dissociation isseen in patients who suffer from Dissociative Identity Disorder. Janet (1889) firstdescribed how traumatized people become "attached" (Freud would later use the term"fixated") to the trauma: "unable to integrate traumatic memories, they seem to have losttheir capacity to assimilate new experiences as well. It is . as if their personalitydefinitely stopped at a certain point and cannot enlarge any more by the addition orassimilation of new elements (p.532)." This suggests that traumatized people are prone torevert to earlier modes of cognitive processing of information when faced with newstresses.
Since the core problem in PTSD consists of a failure to integrate an upsetting experienceinto autobiographical memory, the goal of treatment is find a way in which people canacknowledge the reality of what has happened without having to re-experience thetrauma all over again. For this to occur merely uncovering memories is not enough: theyneed to be modified and transformed, i.e. placed in their proper context and reconstructed into neutral or meaningful narratives. Thus, in therapy, memoryparadoxically becomes an act of creation, rather than the static recording of events whichis characteristic of trauma-based memories.
PTSD as a biologically based disorder.
Abram Kardiner (1941) introduced the notion that "traumatic neuroses" are"physioneuroses" and that patients with PTSD remain on constant alert forenvironmental threat.: "(t)he subject acts as if the original traumatic situation were still inexistence and engages in protective devices which failed on the original occasion. ". (p.
82). In PTSD, the physiological state of chronic overarousal is accompanied bydifficulties in attention and concentration, as well as distortions in informationprocessing, including narrowing of attention onto sources of potential challenge or threat.
It appears that for traumatized people all emotions become angerous. While the functionof their hyperarousal is to prepare them for some form of action in the face of threat, itdoes not build up specific skills and feelings of mastery and control, because theanticipated action is not specific.
Over the past few years it has become increasingly evident that the intensity of the initialsomatic response to a potentially traumatic experience is the most significant predictor oflong term outcome. If the stress is sufficiently overwhelming, the resulting trauma setsup a conditional emotional response in which the body continues to go into a fight, flight,or freeze responses at the least provocation: traumatized people keep experiencing life asa continuation of the trauma, and remain in a state of constant alert for its return. Manytraumatized people who have consciously put the trauma behind them continue toexperience anxiety and increased physical arousal when exposed to situations thatremind them of the trauma, or even to unexpected events such as loud noises, and go intofight/flight reactions, without necessarily being aware of the origin of these extremebehaviors.
Though the biological underpinnings of response to trauma are extremely complex, fortyyears of research on humans and other mammals have demonstrated that trauma(particularly trauma early in the life cycle) has long term effects on the neurochemicalresponse to stress, including the magnitude of the catecholamine response, the durationand extent of the cortisol response, as well as a number of other biological systems, suchas the serotonin and endogenous opioid system. (for an extensive review on thepsychobiology of trauma, see van der Kolk, 1994).
The Symptomatology of PTSD
While Post traumatic stress has been recognized in the poetry of Homer, Shakespeare and Goethe, psychiatry has consistently recognized its existence only since 1980 when PTSD was introduced into the DSM III. Table 1 shows the diagnostic criteria for simple
PTSD. Since that time, there has been a growing literature documenting the posttraumatic symptoms of hyperarousal, hyper-reactivity to stimuli reminiscent of the trauma, avoidance and emotional numbing in a large variety of traumatized populations, including war veterans, children who have experienced physical or sexual assaults, women who have been battered and raped, people exposed to natural disasters, refugees and political prisoners. Regardless of the origin of the terror, the Central Nervous System (CNS) reacts consistently to overwhelming, threatening, and uncontrollable experiences with conditioned emotional responses. For example, rape victims may respond to conditioned stimuli, such as the approach by an unknown man, as if they were about to be raped again, and experience panic.
Intrusive Re-experiencing
Remembrance and intrusion of the trauma is expressed on many different levels, rangingfrom flashbacks, affective states, somatic sensations, nightmares, interpersonal re-enactments, including transference repetitions, character styles, and pervasive lifethemes. Laub and Auerhahn (1993) organized the different forms of knowing along acontinuum according to the distance from the traumatic experience, each form alsoprogressively represents a consciously deeper and more integrated 'level of knowing.'The different forms of remembering trauma range from 1)not knowing; 2) fugue states(in which events are relived in an altered state of consciousness); 3) retention of theexperience as compartmentalized, undigested fragments of perceptions that break intoconsciousness (with no conscious meaning or relation to oneself); 4) transferencephenomena (wherein the traumatic legacy is lived out as one's inevitable fate); 5) itspartial, hesitant expression as an overpowering narrative; 6) the experience ofcompelling, identity-defining and pervasive life themes (both conscious andunconscious); 7) its organization as a witnessed narrative. These various forms ofknowing are not mutually exclusive.
Autonomic hyperarousal. While people with PTSD tend to deal with their environment
by emotional constriction, their bodies continue to react to certain physical and
emotional stimuli as if there were a continuing threat of annihilation. Conditioned
autonomic arousal to traumarelated stimuli has consistently been shown to occur in a
variety of traumatized populations. Autonomic arousal, which serves the essential
function of alerting the organism to potential danger seems to loose that function in
traumatized people: the easy triggering of somatic stress reactions causes people with
PTSD to be unable to rely on bodily sensations to warn them against impending threat.
Instead, the persistent warning signals loose their functions of signals of impending
danger, and cease to alert the organism to take appropriate action.
Numbing of responsiveness. Aware of their difficulties in controlling their emotions,
traumatized people seem to spend their energies on avoiding of distressing internal
sensations, instead of attending to the demands of the environment. In addition, they
loose satisfaction in matters that previously gave them a sense of satisfaction and may
feel "dead to the world". This emotional numbing may be expressed as depression, as
anhedonia and lack of motivation, as psychosomatic reactions, or as dissociative states.
In contrast with the intrusive PTSD symptoms, which occur in response to outside
stimuli, numbing is part of these patients' baseline functioning. In children, numbing has
been observed among elementary school children attacked by a sniper, among witnesses
to parental assault or murder, and among victims of physical or sexual abuse. They
become less involved in playful social interactions, and often are withdrawn and isolated.
After being traumatized, many people stop feeling pleasure from exploration and
involvement in activities, and they feel that they just "go through the motions" of
everyday living. Emotional numbness also gets in the way of resolving the trauma in
psychotherapy: they give up on recovery and it keeps them from being able to imagine a
future for themselves.
Intense emotional reactions and sleep problems. The loss of neuromodulation that is
at the core of PTSD leads to loss of affect regulation. Traumatized people go
immediately from stimulus to response without being able to first figure out what makes
them so upset. They tend to experience intense fear, anxiety, anger and panic in response
to even minor stimuli. This makes them either overreact and intimidate others, or to shut
down and freeze. Both adults and children with such hyperarousal will experience sleep
problems, both because they are unable to still themselves sufficiently to go to sleep, and
because they are fearful of having traumatic nightmares. Many traumatized people report
dream-interruption insomnia: they wake themselves up as soon as they start having a
dream, for fear that this dream will turn into a trauma-related nightmare. They also are
liable to exhibit hypervigilance, exaggerated startle response and restlessness.
Learning difficulties. Physiological hyperarousal interferes with the capacity to
concentrate and to learn from experience. Aside from amnesias about aspects of the
trauma traumatized people often they have trouble remembering ordinary events, as well.
Easily triggered into hyperarousal by trauma-related stimuli, and beset with difficulties
paying attention, they may display symptoms of attention deficit disorder. After a
traumatic experience, people often loose some maturational achievements and regress to
earlier modes of coping with stress. In children, this may show up as an inability to take
care of themselves in such areas as feeding and toilet training; in adults, it is expressed in
excessive dependence and in a loss of capacity to make thoughtful, autonomous
decisions.
Memory disturbances and dissociation. Increased autonomic arousal not only
interferes with psychological comfort, anxiety itself also may trigger memories of
previous traumatic experiences. The administration of lactate, which stimulates the
physiological arousal system, elicits flashbacks and panic attacks in people with PTSD.
Yohimbine injections (which stimulate NE release from the Locus Coeruleus) are able to
induce flashbacks in Vietnam veterans with PTSD. Any arousing situation may trigger
memories of long-ago traumatic experiences and precipitate reactions that are irrelevant
to present demands (see van der Kolk & Fisler, 1994).
In addition to hypermnesia and intrusive memories, chronically traumatized people,particularly children may develop amnestic syndromes related to the traumatic event.
During the stage of life that children, in a stage-appropriate way, try on differentidentities in their daily play activities, children who are exposed to prolonged and severetrauma may be capable of organizing whole personality fragments in order to cope withtraumatic experiences. In the long term, this may give rise to the syndrome ofDissociative Identity Disorder, which may occurs in about 4% of psychiatric inpatients inthe USA (Saxe et al,1993).
Patients who have learned to dissociate in response to trauma are likely to continue toutilize dissociative defenses when exposed to new stresses. They develop amnesia forsome experiences, and tend to react with fight or flight responses to feeling threatened,neither of which may be consciously remembered afterwards. People who suffer fromdissociative disorders are a clinical challenge, including helping them acquire a sense ofpersonal responsibility for both their actions and reactions, while forensically, they are anightmare.
Aggression against self and others
Numerous studies have demonstrated that both adults and children who have beentraumatized are likely to turn their aggression against others or themselves. Being abusedas a child sharply increases the risk for later delinquency and violent criminal behavior.
In one study of 87 psychiatric outpatients (van der Kolk et al.,1991) we found that self-mutilators invariably had severe childhood histories of abuse and/or neglect. There isgood evidence that selfmutilative behavior is related to endogenous opioid changes in theCNS secondary to early traumatization. Problems with aggression against others havebeen particularly well documented in war veterans, traumatized children and in prisonerswith histories of early trauma.
Psychosomatic reactions. Chronic anxiety and emotional numbing also get in the way
of learning to identify and articulate internal states and wishes (Pennebaker,1993).
People traumatized as children frequently suffer from alexithymia - an inability to
translate somatic sensations into basic feelings, such as anger, happiness or fear. This
failure to translate somatic states into words and symbols causes them to experience
emotions simply as physical problems. This naturally plays havoc with intimate and
trusting interpersonal communications. These people have somatization disorders and
relate to the world through their bodies. They experience distress in terms of physical
organs, rather than as psychological states (Saxe et al., 1994).
Developmental level affects the behavioral and biological concomitants
of trauma.
Over the past thirty years people have slowly started to unravel the differential effects of
trauma at various age levels. Modern psychiatry has begun to reconsider the ways in
which failure of attachment and traumatic separation affect the developing organism.
Bowlby (1969) has emphasized that attachment behavior is first of all a vital biological
function, indispensable for both reproduction and survival. A rapidly expanding body of
research has shown that disturbances of childhood attachment bonds can have long term
neurobiological consequences. In addition to the disturbances in affect regulation, a large
variety of studies, both in animals and in humans, have shown that childhood abuse,
neglect, and separation have far-reaching biopsychosocial effects, including lasting
biological changes which affect the capacity to modulate emotions, difficulty in learning
new coping skills, alterations in immune competency, and impairment in capacity the to
engage in meaningful social affiliation. Aided by work on other animal species, a
voluminous research literature on the effects of childhood physical and sexual abuse, and
the Field Trials for the DSM IV, it has become understood that there are critical stages in
the development of the CNS that make children particularly vulnerable to develop lasting
disturbances secondary to abuse, neglect and separation. Aware of the fact that trauma at
an early age has profound effects on affect regulation, levels of consciousness, tendency
to organize experience on a somatic level, and to make characterological adaptations to
chronic exposure to danger and fear, the DSM IV PTSD committee recommended an
expanded definition of PTSD for inclusion in the DSM IV. The DSM IV classification
system now recognizes the pervasive effects of trauma on the totality of a person's
personality functioning in its new section on "associated features". Table 2 shows the
features of the associated features of PTSD in the DSM-IV.
PRINCIPLES OF TREATMENT
The treatment of PTSD has three principal components: 1) processing and coming to terms with the horrifying, overwhelming experience, 2) controlling and mastering physiological and biological stress reactions, 3) re-establishing secure social connections The aim of these therapies is to help the traumatized individual to move from beingdominated and haunted by the past to being present in the here and now, capable ofresponding to current exigencies with his or her fullest potential. Thus, the trauma needsto be placed in the larger perspective of a person's life, as a relatively isolated historicalevent, or series of events, that occurred at a particular time, and in a particular place, andthat can be expected to not recur if the traumatized individual takes charge of his or herlife. Tragically, many traumatized people are involved in situations of ongoing trauma, inwhich they have little or no personal control over what happens to them. However, evenunder those circumstances, learning how to properly assess what is going on andplanning one's responses, possibly in collaboration with other people, still can beexpected to have significant psychological benefits.
Acute trauma.
Immediately after the trauma, the emphasis needs to be on self-regulation and onrebuilding. This means the re-establishment of a sense of security and predictability, andactive engagement in adaptive action. Only a limited proportion of people who aretraumatized develop PTSD. Most traumatized people seem to be able to successfullynegotiate these initial adaptive phases without succumbing to the long term progressionof their acute stress reaction into PTSD. For them, the trauma becomes merely a terribleexperience that happened to them some time in their past. It is quite unclear whethertalking about what has happened is always useful in preventing the development ofPTSD. Some surprising findings have come out of careful Critical Incidence StressDebriefing research: the few controlled studies that have examined the preventativeeffect of debriefing immediately following exposure to a traumatic event have suggesteda poorer outcome following debriefing as compared with no intervention(McFarlane,1994). Give the paucity of controlled studies, we are left with the clinicalimpression that the initial response to trauma consists of reconnecting with ordinarysupportive networks, and of engaging activities that re-establish a sense of mastery. It isobvious that the role of mental health professionals in these initial recuperative efforts isquite limited.
The Need for Phase Oriented Treatment. Trauma needs to be treated differently at
different phases of people's lives following the trauma, and at the different stages of the
disorder PTSD. Treatments that may be effective at some stages of treatment might not
be effective at others. For example, on a pharmacological level, initial management with
drugs that decrease autonomic arousal will decrease nightmares and flashback, promote
sleep, and are likely to prevent the kindling effects that are thought to underlie the long-
term establishment of PTSD symptomatology. These same drugs, once the Disorder has
been established have, at best, a palliative function, and serotonin re-uptake blockers,
which seem to have little immediate benefit, can be immensely helpful in allowing
people to attend to current asks, and not to dwell on past fears, interpretations, and
fixations. In this context, it is interesting to note that Foa et al. (1991) found that in the
initial stages of treatment of rape victims Stress Inoculation Training turned out to be as
effective a treatment of PTSD as was Prolonged Imaginal Exposure. However, on
follow-up, imaginal flooding had superior results to stress inoculation. If there aredifferential effects of therapeutic modalities within a four month time frame, it is likelythat there would be differential effects over longer time spans. It is likely that someforms of therapy might be effective at some stages, but have negative outcomes at otherphases of the illness. Another instance is abreaction. It appears that abreaction as atreatment is most effective early in the course of the illness, and that its effectivenessdecreases over time. For example, exposure therapy using "flooding" techniques havebeen found to worsen the symptoms of some patients, particularly in those in whom thefocal trauma was decades earlier (Pitman et al., 1991). When intrusions of fragments ofthe trauma are the predominant symptom, exposure and desensitization may be what ismost required. At a later stage of the progression of the disorder, when people haveorganized their entire lives around avoidance of triggers of the trauma, and approachother people as potential triggers of traumatic intrusions, helplessness, suspicion, anger,and interpersonal problems may dominate the symptom picture. When that is the case,primary attention needs to be paid to stabilization in the social realm.
Psychotherapeutic Interventions
The key element of the psychotherapy of people with PTSD -- as perhaps for allpsychotherapy -- is the integration of the alien, the unacceptable, the terrifying, theincomprehensible. Life events initially experienced as alien, as if imposed from outsideupon passive victims, must come to be "personalized" affectively as integrated aspects ofone's history and life experiences (van der Kolk & Ducey,1989). The massive defenses,initially established as emergency protective measures, must gradually relax their gripupon the psyche, so that dissociated aspects of experience do not continue to intrude intoone 's life experience and thereby threaten to retraumatize an already traumatized victim.
Psychotherapy must address two fundamental aspects of PTSD: the deconditioning ofanxiety, and the pervasive effects that trauma has on the way victims views themselvesand the world. In only the simplest cases will it be sufficient to decondition the anxietyassociated with the trauma. In the vast majority of patients, both aspects will have to betreated, which means the use of a combination of procedures for Reconditioning anxiety,for changing beliefs, and for developing a cognitive system that somehow allows aperson to continue to cope effectively in a world that now is known to be capable of greatdestructiveness (Epstein, 1991).
1) Stabilization
In the treatment of simple cases of PTSD, it is perhaps possible to move quickly, toactivating the traumatic memory. In more complex cases, it should be part of a moreencompassing treatment model, which must include careful preparation, with an eye onproviding the patient with a capacity to feel safe while accessing traumatic material (e.g.
Brown & Fromm,1986). For the past century, psychotherapeutic clinicians have basicallyadopted a phase-oriented model that consists of (1) reintegration and rehabilitation (cf.
van der Hart, Brown & van der Kolk, 1989; Herman,1992). In the first phase thefoundation is laid that enables patient to deal with the challenge of confronting thetrauma. The patient is helped with establishing more stability and safety in daily life,including social support, stress inoculation, ways of controlling symptoms and ways ofcontaining intrusive memories (e.g. van der Hart et al., 1993). Psychopharmacologicalmanagement often is an integral part of stabilization.
2) The identification of feelings by verbalizing somatic states.
The function of emotions is to alert people to the occurrence, significance, and nature ofsubjectively significant events (Krystal,1978) Ordinarily, emotions are de-activated whenschemas and situations have been realigned (e.g., by taking action that conformssituations to schemas, or by amending schemas to better fit situations) (Horowitz, 1986).
Thus, emotions function as signals to readjust one's expectations of the world and to takeadaptive action. Krystal (1978) first noted that in people with PTSD emotions seem toloose much of their alerting function: a dissociation is set up between emotional arousaland goal directed action. Traumatized people loose their capacity to interpret themeaning of their emotional arousal, which thus becomes irrelevant is a current signal.
Unable to interpret the meaning of their emotional arousal, feelings themselves becomeendowed with a negative valence: because no release can be found in adaptive action,emotions merely become reminders of one's inability to affect the outcome of one's life.
Hence, aside from the concrete, usually visual, reminders of the trauma, feelings ingeneral come to be experienced as traumatic reminders, and are to be avoided (van derKolk & Ducey,1989) .
Unable to neutralize affects with adaptive action, traumatized people tend to experiencetheir affects as somatic states: either through their smooth, or striated musculature. Thus,people with PTSD tend to somatize (Saxe et al, 1994, ) or to discharge their emotionswith actions that are irrelevant to the stimulus that precipitated the emotion: withaggressive actions against self or others (van der Kolk et al ,1991). When thedisorganizing intrusions can be understood as failures of integration of traumaticexperiences into the totality of one's life, the psychotherapist is in a position to recognizeseemingly overwhelming affective experiences as actual reliving of past terror. One'snatural proclivity in psychotherapy is to help the patient avoid experiencing undue pain;yet the patient's affective experiences are part and parcel of healing and integration. Thepsychotherapist who understands the nature of trauma can aid the process of integrationby staying with the patient through his suffering, by providing a perspective that thesuffering is meaningful and bearable, and by helping in the mastery of trauma throughputting the experience into symbolic, communicable form, such as words, thoughts, andfeelings. The patient's "repeating" the trauma in action is the forerunner to his"remembering" and symbolizing it in words, which in turn is the precursoraccompaniment to his "working it through" in emotional experience 3) Deconditioning of traumatic memories and responses.
This consists of: (a) controlled activation of the traumatic memories, and (b). correctionsof faulty traumatic beliefs. The critical issue is to introduce the capacity to flexiblyremember the trauma. In order for this to occur, some new information that isincompatible to the traumatic memory must be introduced (Foa et al., 1989). The mostimportant new information is probably the fact that the patient is able to confront thetraumatic memory by a trusted therapist in a safe environment (van der Hart &Spiegel,1993). In order to help the patient regulate emotional arousal, secure attachmentmay be even more important than evoking the traumatic memories. Therefore, it isimportant for the patient to establish and maintain an emotional connection with thetherapist. While behavioral therapists speak about exposure-procedures, which are eithersystematic desensitization procedures or implosive therapy or flooding procedures, theyneglect to write about the intensely personal element in all psychotherapeutic procedures,which is a critical element in the success of effective treatment. So, while these cliniciansand researchers almost exclusively present their data about decreases of fear or anxietythrough controlled exposure to (a) the stimulus components (environmental cues), (b) theresponse components (e.g. motoric actions, heart pounding), and the meaning elements (e.g. cues regarding morality and guilt) of the traumatic memory (Foa & Kozack, 1986;Foa et al., 1989; Lidz & Keane, 1986), their results are most likely heavily affected bytheir personal investment in the well-being of their patients, which is communicated andtranslated into a subjective sense of safety.
According to Foa & Kozak (1985) two conditions are required for anxiety reduction inthe treatment of PTSD: 1) a person must attend to fear-relevant information in a mannerthat will activate his/her own fear memory. As long as the fear is not experienced, thefear structure cannot be modified. 2) in order to form a new, non-fear structure, some ofthe information that evoked the fear must be absent in the new context in which the fearis being provoked. Exposure to information consistent with a fear memory would beexpected to strengthen the fear (i.e., sensitize and thereby increase the likelihood ofdeveloping PTSD). Hence the critical issue in treatment is to expose the patient to anexperience that contains elements that are sufficiently similar to an existing traumaticmemory in order to activate it, and at the same time for it to be an experience thatcontains aspects that are incompatible enough to change it (for example experiencing atraumatic memory in a safe and controllable environment, being able to evoke atraumatic image, without feeling overwhelmed by the associated emotions).
There are at least two significant problems with this exposure technique: 1) Becauseexcessive arousal interferes with the acquisition of new information, excessive arousalimpedes habituation (Strian & Klicpera, 1978). When that occurs, the fear structure willnot be corrected, but instead, will be confirmed: instead of promoting habituation, itaccidentally fosters sensitization. 2) An additional serious obstacle to effective treatmentis that the strong response elements in the PTSD structure may promote avoidance:strong fear and discomfort motivates people who suffer from PTSD to avoid or escapeconfrontation with situations that remind him/her of the trauma, in order to overcome theintrusive, sensorimotor elements of the trauma, a person must transform the traumatic(non-verbal) memory into a personal narrative, in which the trauma is experienced as ahistorical event that is part of a person's autobiography. This entails being able to tell thestory of the shocking event without reexperiencing it. It is generally assumed that onceall relevant elements of the total traumatic experience have been identified andthoroughly and deeply examined and experienced in the therapy, successful synthesiswill take place. The work by Resick & Schnicke (1992) supports the notion that exposureof all elements of the trauma, and their associated shifts in perception of self and othersdoes lead to successful resolution of trauma-related symptomatology.
4) Restructuring of trauma-related schemes of internal and external reality.
Apart from treatment needing to address specific trauma-related memories, and fosteringde-conditioning, treatment needs to address the effects of the trauma on people'sperceptions of themselves, and the world around them. People are meaning-makingcreatures. As we develop we organize our world according to a personal theory of reality,some of which may be conscious, but much of which is an unconscious integration ofaccumulated experience. These mental schemas organize psychological experience viathe process of assimilation and accommodation and assure continuity of one's identity(Horowitz,1991). Although most people cannot clearly articulate the content of theirmental schemes, they nonetheless determine what sensory input is selected for furthercoding and categorization. Adaptive resolution to a stressful experience consists of themodification, or accommodation one's view of self and others that permits adaptiveaction and continued attention to the exigencies of daily life. In order to successfully dealwith a distressing experience, it is necessary to not generalize from that experience to the totality of existence, but to view it merely one terrible event that has taken place at aparticular place at a particular time (Epstein, 1991).
Traumatic experiences, i.e. experiences that do not fit into people's personal schemes,may be assimilated (directly taken in). ("That never happened." "I caused it to happen."),or people may accommodate to the experience by altering their conceptions of the world("There is no safe place." "This happened because people are out to hurt me.")(Resick &Schnicke,1992, Hollon and Garber,1988).
Traumatic experiences are not only processed by means of currently existing mentalschemes, but they may also activate latent self-concepts and views of relationships thatwere formed earlier in life. This activation of latent schemes is particularly relevant forpeople with prior histories of trauma, even in those who subsequently have been able tomake a successful adaptation. When trauma activates these earlier self-schemas, thesewill compete and co-exist with more mature schemes in explaining cause and effectrelationships in regards to the trauma. These different, and often competing mentalschemes then will determine the psychological organization of the traumatic experience.
Psychotherapy needs to specifically address how the trauma has affected people's senseof self-efficacy, their capacity for trust and intimacy, their ability to negotiate theirpersonal needs, and their ability to feel empathy for other people (McCann & Pearlman,1990) 5) Exposure to restitutive experiences.
Considering the fact that the central psychological preoccupation of traumatized peopleis either the reliving or the warding off of the memory of the trauma, there is little roomfor new, gratifying experiences which might allow for reparation of past injuries to theself. Patients need to actively expose themselves to experiences that provide them withfeelings of mastery and pleasure. Engagement in physical activities, such as sports orwilderness ventures, gratifying physical experiences, such as massages, or artisticaccomplishments may be experiences that patients build up that are not contaminated bythe trauma, and which may serve as a core of new gratifying experiences.
GROUP PSYCHOTHERAPY
Emotional attachment is the primary protection against being traumatized: people have always gathered in communities and organizations to help them deal with outside challenges: we seek close emotional relationships with others in order to help us anticipate, meet and integrate difficult experiences. Contemporary research (e.g.
Quanterelli, 1985; Holen,1990) has shown that as long as the social support network remains intact, people are relatively well protected against even catastrophic stresses. For young children, the family usually is a very effective source of protection against traumatization, and most children are amazingly resilient as long as they have a caregiverwho is emotionally and physically available (Wender,1989; van der Kolk, Perry & Herman,1991, McFarlane,1988). Mature people also rely on their families, colleagues and friends to provide such a trauma membrane. In recognition of this need for affiliation as a protection against trauma, it has become widely accepted that the central issue in acute crisis intervention is the provision and restoration of social support (Lystad, 1988; Raphael,1986; Mitchell ,1983). However, curiously, research has not supported the efficacy of standardized Stress Debriefing interventions following trauma.
The task of group therapy and community interventions is to help victims regain a senseof safety and of mastery. After an acute trauma, fellow victims often provide the mosteffective short-term bond because the shared history of trauma can form the nucleus ofretrieving a sense of communality.
Regardless of the nature of the trauma, or the structure of the group, the aim of grouptherapy is to help people actively attend to the requirements of the moment, withoutundue intrusions from past perceptions and experiences. Group therapy is widelyregarded as a treatment of choice for patients with trauma histories. It has been used forvictims of interpersonal violence (Mitchell, 1983) natural disasters (Lystad,1988;Raphael, 1986), childhood sexual abuse (Herman & Shatzow ,1987, Ganzarian &Buchele, 1987; Schacht et al, 1990), rape (Yassen & Glass,1984), spouse battering(Rounsaville et al,1979), concentration camps (Danielli,1985) and war trauma (Parson,1985). In a group of people who have gone through similar experiences, mosttraumatized people eventually are able to find the appropriate words to express what hashappened to them. As was observed almost fifty years ago: "by working out theirproblems in a small group they should be able to face the larger group, i.e., their world,in an easier manner" (Grinker & Spiegel,1946).
There are many levels of trauma-related group psychotherapies, with different degrees ofemphasis on stabilization, memory retrieval, bonding, negotiation of interpersonaldifferences, and support. However, to varying degrees, the purpose of all trauma relatedgroups is to 1) stabilize psychological and physiological reactions to the trauma, 2) toexplore and validate perceptions and emotions, 3) to retrieve memories, 4) to understandthe effects of past experience on current affects and behaviors and 5) to learn new waysof coping with interpersonal stress (see van der Kolk,1992) .
PSYCHOPHARMACOLOGICAL TREATMENT
While it is widely recognized that PTSD is a "physioneurosis", i.e. that it is based on psychological manifestations of biological changes, systematic psycho-pharmacological studies of PTSD are scarce and almost entirely limited to tricyclic antidepressants and MAO inhibitors. As of July, 1994, a total of only 134 patients with PTSD had been studied in double-blind placebo controlled studies. The treatment effects of the psychotropic agents examined in these systematic studies have been quite modest (Davidson, 1992). In addition, in open studies and clinical reports, usefulness has been claimed for benzodiazepines, lithium carbonate, carbamazepine, clonidine and beta adrenergic blockers (van der Kolk, 1987; Davidson, 1988; Friedman, 1988), but their efficacy has not been confirmed in double-blind, placebo controlled studies.
Three double-blind trials of tricyclic antidepressants have been published (Frank et al.,1988; Kosten et al., 1991; Davisdon et al., 1990; Reist et al., 1989), two of whichdemonstrated some improvement in PTSD symptoms (Frank et al., 1988; Kosten et al.,1991; Davidson et al., 1990). Davidson et al (1990), studying in-patient and out-patientveterans of World War II and Vietnam, showed that amitriptyline caused a decrease inoverall PTSD, primarily by decreasing avoidant symptoms. In two reports of essentiallythe same sample, Frank et al. (1988), Kosten et al. (1991) and their collaborators foundthat imipramine was more effective than placebo in out-patient Vietnam veterans,particularly decreasing intrusive symptoms. On the other hand, Reist et al (1989) foundno significant difference between desipramine and placebo in a four week crossover trial.
All three studies report a lack of placebo response in war veterans with chronic PTSD.
Pheneizine sulfate has been used in two double-blind trials, with a total of 40 subjects.
One study was positive (Frank et al., 1988; Kosten et al., 1991) showing improvement inintrusive symptoms of PTSD, without significant effect on avoidant symptoms. Theother failed to demonstrate a positive effect of pheneizine on PTSD symptoms in amixed civilian/combat veteran population (Shetatsky,1988).
During the past few years evidence has accumulated that the serotonin reuptake blockersare likely to be the most effective drugs in the treatment of chronic PTSD (e.g. Davidsonet al., 1991; March, 1992; Nagy et al.,1993). In our own studies (van der Kolk et al 1994)we were able to show that fluoxetine can have profound effects on numbing arousal, and,to a lesser degree, on intrusions. Fluoxetine had a significant positive effect on thedimensions of affect dysregulation, distorted relationships with others and loss ofsustaining beliefs. Positive effects became evident after five weeks on active drug wassufficient to demonstrate significant improvement Fluoxetine was not only effective inalleviating the core symptoms of PTSD, but also the associated features: affectdysregulation, distorted relationships with others and loss of sustaining beliefs. Our studyshowed that the beneficial effect of fluoxetine on PTSD is not a function of itsantidepressant effects, but, instead, by making people with PTSD feel less numb andmore in tune with their surroundings, fluoxetine is likely to make them feel betterequipped to deal with residual trauma-related fears, recollections and intrusions.
The efficacy of this serotonin reuptake blocker on PTSD symptomatology raisesintriguing questions about the possible role of serotonin in the psychopathology ofPTSD. The increased availability of serotonin in the hippocampus may activateinhibitory pathways in the limbic system that prevent the initiation of habitual emergencyresponses (van der Kolk, 1994). Animal research has shown that serotonin receptorblockers reverse the suppression of fear-induced behavior, probably because an increasein available serotonin in the limbic system amplifies the signals necessary to distinguishpunishment from reward (Gray, 1988) CONCLUDING REMARKS
After a trauma which fully confronts people with their existential helplessness and vulnerability, life can never be exactly the same: the traumatic experience will somehow become part of a person's life. Sorting out exactly what happened and sharing one's reactions with others can make a great deal of difference in one's eventual adaptation.
Putting the feelings and cognitions related to the trauma into words is essential in the treatment of post traumatic reactions. After intense efforts to ward off reliving the trauma, therapists cannot expect that the resistances to remember will suddenly melt away under their empathic efforts. The trauma can only be worked through when a secure bond is established with another person; this then can be utilized to hold the psyche together when the threat of physical disintegration is re-experienced.
Failure to approach trauma related material gradually is likely to lead to intensification ofposttraumatic symptomatology, leading to increased somatic, visual or behavioralreexperiences. Once the traumatic experiences have been located in time and place, aperson can start making distinctions between current life stresses and past trauma, anddecrease the impact of the trauma on present experience. Talking about the trauma is notenough: trauma survivors need to take some action that symbolizes triumph overhelplessness and despair. The Holocaust Memorial Yad Vashem in Jerusalem and theVietnam Memorial in Washington, DC, are good examples of symbols for survivors tomourn the dead and establish the historical and cultural meaning of the traumatic events.
Most of all, they serve to remind survivors of the ongoing potential for communality andsharing. This also applies to other survivors who may have to build less visiblememorials and common symbols around which they can gather to mourn and expresstheir shame about their own vulnerability. This may take the form of writing a book,taking political action, helping other victims, or any of the myriad of creative solutionsthat human beings can find to defy even the most desperate plight.
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SIMPLE PTSD (DSM IV)
A. 1) Exposure to life threatening experience
2) Intense subjective distress upon exposure B. Reexperiencing the trauma:
1) recurrent intrusive recollections, or repetitive play,2) recurrent dreams3) suddenly acting or feeling as if the traumatic event were recurring4) intense distress upon re-exposure to events reminiscent of trauma5) physiological reactivity upon reexposure C. Persistent avoidance or numbing of general responsiveness.
1) efforts to avoid thoughts or feelings associated with trauma2) efforts to avoid activities3) psychogenic amnesia4) diminished interest in significant activities5) feelings of detachment of estrangement6) sense of foreshortened future D. Persistent symptoms of increased arousal
1) difficulty falling of staying asleep2) irritability or outbursts of anger3) difficulty concentrating COMPLICATED PTSD.
I. Alteration in Regulation of Affect and Impulses
A. Affect RegulationB. Modulation of AngerC. Self-DestructiveD. Suicidal PreoccupationE. Difficulty Modulating Sexual involvementF. Excessive Risk taking II. Alterations in Attention or Consciousness
A. AmnesiaB. Transient Dissociative Episodes and Depersonalization III. Somatization
A. Digestive SystemB. Chronic PainC. Cardiopulmonary SymptomsD. Conversion SymptomsE. Sexual Symptoms IV. Alterations in Self-Perception
A. IneffectivenessB. Permanent DamageC. Guilt and ResponsibilityD. ShameE. Nobody Can UnderstandF. Minimizing V. Alterations in Perception of the Perpetrator
A. Adopting Distorted BeliefsB. Idealization of the PerpetratorC. Preoccupation with Hurting Perpetrator Vl. Alterations in Relations with Others
A. Inability to TrustB. RevictimizationC. Victimizing Others Vll. Alterations in Systems of Meaning
A. Despair and HopelessnessB. Loss of Previously Sustaining Beliefs David Baldwin's Trauma Information Pages
http://www.trauma-pages.com/
Eugene, Oregon USA
(541) 686 2598

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