Rachel Yehuda, Ph.D.

A failure to consider vulnerability

 factors in the development of PTSD

may ultimately impede clinical treatment...

Only recently has the field of

traumatic stress begun to consider

resilience and vulnerability  and

particularly the latter  as relevant to

understanding the course of

adaptation to trauma. Given the

substantial number of trauma

survivors who either do not develop,

or recover from PTSD, knowledge of

these factors appears to be essential in

understanding the nature and

treatment of this disorder. Clinicians

 have been eager to discuss resilience

to trauma and to elucidate the coping behaviors that lead to restitution

of symptoms, or to adaptation to trauma. Certainly, many specialized

PTSD treatments involve training trauma survivors to use coping

skills to better manage their reactions to traumatic reminders.

Talking about vulnerability to PTSD, however, is quite another

matter, and is still approached with ambivalence in many clinical and

academic circles. Many involved in treating trauma survivors feel that

discussions of vulnerability to PTSD may betray their clients by

implying that their symptoms are not a result of the events that they

may have experienced, but rather, an underlying constitutional

weakness. Talking about vulnerability factors in a post-DSM era smacks

of the now unpopular concept of neurosis and potentially endangers

the concept of PTSD by de-emphasizing the role of the traumatic

event in the etiology of this disorder. As the notion of vulnerability

to PTSD does tend to contradict one of the original tenets on which

the diagnosis was based  that symptoms are solely a result of trauma

exposure  it is important to approach this idea with caution.

On the other hand, a failure to consider vulnerability factors in

the development of PTSD may ultimately impede clinical treatment

of the trauma survivor. Although clinicians may feel an obligation to

uphold the original ideology on which PTSD was developed, to the

extent that vulnerability factors are important, this may deprive the

patient who is treated using a more limited therapeutic intervention

than that might otherwise be applied if vulnerability factors were

considered. Fortunately, the clinician no longer has to choose between

the political correctness of ignoring vulnerability and the clinical

appropriateness of embracing it, because contemporary knowledge about

vulnerability has been incorporated into a new ideology of PTSD as

reflected in the DSM-IV. Indeed, the DSM-IV conception of PTSD has

moved away from some of the original formulations of this disorder in

the direction of embracing the idea of individual differences in stress

responsiveness.

Historic Reluctance to Consider the Role of Vulnerability

in Traumatic Stress Responses

The diagnosis of PTSD was established in order to describe the

enduring psychological consequences following exposure to traumatic

events (for a more comprehensive review of the conceptual history of

PTSD see 1). An important consideration in developing this diagnosis

was the need to differentiate between the transient consequences

associated with chronic or everyday stress such as divorce, job loss, coping

with chronic illness or occupational stress, and the persistent and more

debilitating effects of overwhelming, potentially life-threatening stress

such as rape, torture and war. Although it was known that exposure to

chronic, but non-life threatening stress could be associated with severe

health consequences, it was also felt that the adverse effects would dissipate

when the stressors were no longer present. In contrast, the traumatic

stress response, as conceptualized by the diagnosis of PTSD, described

adverse effects that continued long after the event had passed.

Another difference between chronic and traumatic stress was that

the effects of the former develop slowly over time, whereas traumatic

stress reactions are sudden. In chronic, non-traumatic stress the body is

not overwhelmed by a great moment of physiologic upheaval, but rather,

continued on page 3

RESILIENCE AND VULNERABILITY FACTORS 1

THERAPEUTIC FOLLOW-UP IN CHRONIC PTSD 6

NEW DIRECTIONS 11

WOMEN AND TRAUMA: A CLINICAL FORUM 12

TREATMENT OF PTSD WITH PSYCHOTIC SYMPTOMS 14

NC-PTSD EDUCATION & SUPPORT SERVICES 20

RESILIENCE AND VULNERABILITY FACTORS

IN THE COURSE OF ADAPTATION TO TRAUMA

INSIDE THIS ISSUE

Winter 1998, Volume 8, Issue 1, ISSN-1052-7168

 Rachel Yehuda, Ph.D.
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

2

This issue of the Quarterly we are pleased to present a range

of articles discussing the role of pre-disposing factors in the

development of PTSD, the challenge of measuring treatment

outcomes, and treatment for veterans with PTSD and psychosis.

This issue also marks a change in our editorial staff.

For many years, the examination of predisposing factors as

determinants of PTSD was controversial, i.e., many held the

conviction that it was unnecessary to look at associated risk

factors beyond the temporal frame of the traumatic event.

When the disorder was formally recognized in 1980, the validity

of the PTSD construct rested largely on the data provided by

patient self-reports. Today, there is added empirical biological

evidence supporting PTSD as a diagnostic entity. The biologic

validation of PTSD asserts Rachel Yehuda in her article

discussing resilience and vulnerability factors, has offered the

field an opportunity to grapple with the issues of vulnerability

without endangering the initially fragile construct of PTSD.

Demonstrating that positive change can occur in the course

of treating chronic PTSD is often challenging to administrators

and clinicians. The biopsychosocial sequalae associated with

PTSD suggest that multimodal measurements are necessary.

In the article Therapeutic Follow-Up, Barbara Niles, Elana

Newman, and Lisa Fisher discuss the complexities involved in

measuring the course of PTSD and underscore the need for

utilizing multiple measurement techniques across time. This

issue also features a look at treatment of PTSD when psychotic

features are also present. Madeline Uddo, Frederick Sautter,

and Larry Pardue describe a treatment model and present their

research findings related to a clinical domain not often addressed

in the literature.

For the last four years, Marylene Cloitre and Dudley Blake

have generously donated their time and skills to the publication

efforts of the Quarterly. Dr. Cloitre has overseen the Womens

Column since its inception, contributing many of the thoughtful

columns herself. As Associate Editor, Dr.. Blakes ability to

further sharpen even the sharpest of writings greatly served

the efforts to transition from a newsletter to a more academic

and clinically oriented publication. To both Dr. Cloitre and Dr.

Blake, thank you. In their place, we welcome Marie Caulfield,

Annabel Prins, Gregory Leskin and Eve Carlson to the Clincial

Quarterly staff. Drs. Caulfield and Prins will be overseeing the

column Women and Trauma and Drs. Leskin and Carlson

have become our new Associate Editors. We look forward to

the unique perspective each of these skilled research/clinicians/

writers bring to our publication.

Lastly, we are happy to announce that past issues of the Clinical

Quarterly have been posted on our NC-PTSD Webpage. Volume

7(4) appears in its original published format. Plans are underway

to post each of the previous articles. At this point, a select number

of text only articles are posted from Volumes 1-7. Please

visit our webpage:http://www.dartmouth.edu/dms/ptsd/.

NATIONAL CENTER FOR PTSD

Executive Director

Matthew J. Friedman, M.D., Ph.D.

VAMC/ROC White River Junction

Vermont 05009

Education and Clinical Laboratory Division

Fred Gusman, M.S.W., Director

VAMC, Palo Alto, California 94304

Pacific Islands Division

Sarah Miyahira, Ph.D., Acting Director

Honolulu, Hawaii 96813

Behavioral Science Division

Terence Keane, Ph.D., Director

VAMC, Boston, Massachusetts 02130

Womens Health Science Division

Jessica Wolfe, Ph.D., Director

VAMC, Boston, Massachusetts 02130

Editor

Managing Editor

Executive Editor

Associate Editors

Assistant Editor

Graphic Designers

Clinical Quarterly Staff

Please feel free to contact us at the Education Division: FTS 463-2673/2494; commercial number 650-493-5000 ext. 22673/22494; or E-mail: bhh @ icon.palo-alto.med.va.gov

Please address all correspondence to : Editor, National Center for PTSD Clinical Quarterly, VA Palo Alto Health Care System, 795 Willow Rd (352E117), Menlo Park, CA 94025

FROM THE EDITOR...

Neuroscience Division

Dennis Charney, M.D., Director

VAMC, West Haven, Connecticut 06516

Northeast Program Evaluation Center

Robert Rosenheck, M.D., Director

VAMC, West Haven, Connecticut 06516

Bruce H. Young, L.C.S.W.

Joe I. Ruzek, Ph.D.

Fred D. Gusman, M.S.W.

Eve B. Carlson, Ph.D.

Gregory A. Leskin, Ph.D.

John Aboytes, B.A.

Gregory A. Leskin, Ph.D.

Bruce H. Young, L.C.S.W.

Dennis V. Derecho, M.P.H.

 Bruce H. Young, Editor

National

Center

for

PostTraumatic

Stress

Disorder
Volume 8 (1) Winter 1998

3

NC-PTSD Clinical Quarterly

RESILIENCE AND VULNERABILITY FACTORS

To assume that explanations other than trauma

severity might be involved in producing the chronic

aftermath of PTSD was to blame the victim for their

legitimate reactions to experiences that befell them.

suffers from the gradual erosion of physiologic systems that render

the individual vulnerable to a host of physical and psychological

illnesses. Chronic stress is associated with feeling overwhelmed.

Traumatic stress results, quite specifically, in a fear response (which

might also feel overwhelming). In PTSD, the damage done to the

individual is thought to occur as a result of activating fear centers in

the brain which initiate a cascade of biological and psychological

responses (2, 3). Given the differences between chronic and traumatic

stressors, it should not be surprising that biologic studies of the

hormonal systems involved in stress responses have revealed very

distinct neuroendocrine profiles for chronic stress and the traumatic

stress response associated with PTSD (4).

In addition to differentiating between the effects of nontraumatic and traumatic stress, the diagnosis of PTSD also offered an

opportunity for a more universal description of the response to trauma.

Prior to the establishment of the diagnosis of PTSD, syndromes,

war neurosis,  and battered wife syndrome described symptoms

associated with each of these distinct events. The idea behind PTSD

was that once a certain threshold of severity was reached, symptoms

were not dependent on the nature of the specific event that occurred.

Thus, the diagnosis of PTSD represented an attempt to define

symptoms common to all trauma survivors. The major assumption

behind the diagnosis was that the symptoms occurred because of the

exposure to the traumatic stress. Implicit in this idea was the

presumption that most individuals who experienced traumatic events

would develop symptoms regardless of any pre-traumatic

considerations. To assume that explanations other than trauma severity

might be involved in producing the chronic aftermath of PTSD was

to blame the victim for their legitimate reactions to experiences that

befell them. Furthermore, because of the political difficulties in

establishing the diagnoses, there may have been an unwitting feeling

that talking about vulnerability in the early phases of the disorder 

before it was fully accepted in mental health as a legitimate diagnostic

entitymight endanger the concept of PTSD and quite possible lead

to its disappearance. Thus began a virtual taboo against discussion

issues relating to vulnerability.

Influence of Scientific Findings on Vulnerability Models for PTSD

At the time the diagnosis was established no one knew the

prevalence of either trauma exposure or PTSD. One of the major

observations from epidemiological studies was that exposure to

horrible, life-threatening events was disturbingly common among

people. The most recent epidemiological study estimated that about

90% of citizens in the United States are exposed to at least one

traumatic event as defined by the DSM-IV in the course of their lives

(5). Many individuals are exposed to more than one traumatic event

in their lives (6). However only about 14%  18% of all women and

10% of all men in the United States  develop PTSD in response to

these events (5). It is interesting to speculate how this knowledge

might have affected formulations of PTSD in the DSM.

DSM-IV dealt with the epidemiological data by adding the clause

to Criterion A that the traumatic event must be accompanied by the

subjective response of fear, helplessness, or horror. This clause

provided an acknowledgement that there is diversity in the responses to

traumatic events. Indeed, subjective responses to a given event could

not be assumed. The stipulation in DSM-IV that individuals must

experience a subjective response to an event now makes the study of

risk factors necessary rather than inappropriate. Furthermore, the

implication of vulnerability or risk factors for PTSD is not nearly as

threatening to the conception of PTSD in the mid and late  90s as it

might have been in the early 80s due to the proliferation of biologic

studies in PTSD. During the time that elapsed between DSM and

DSM-IV, numerous biologic studies have provided important validation

for the disorder of PTSD. In particular, the findings of neuroendocrine

studies have demonstrated that the hormonal basis of PTSD is distinct

from that of chronic stress and other psychiatric disorders. The biologic

validation of PTSD has offered the field an opportunity to grapple with

issues of vulnerability without endangering the initially fragile construct

of PTSD.

Political Correctness of Vulnerability Models of PTSD

One of the most salient predictors of PTSD appears to be the

severity of the traumatic event. The DSM had initially hoped to unite

the experience of trauma under one set of symptoms. This implied

that traumatic vs. non-traumatic stress might best be considered

dichotomous. However, empirical research demonstrated that traumatic

events could be considered as existing on a continuum. Not surprisingly,

events such as torture or prolonged victimization are associated with

the highest estimates for chronic PTSD. The prevalence of chronic

PTSD among prisoners of war and concentration camp survivors is

about 50% (7, 8). In contrast, the prevalence rate of chronic PTSD in

survivors of natural disasters is about 4% (9). The dose-response

relationship between severity of the trauma and the subsequent

development of PTSD suggests that vulnerability factors may be

particularly important as one moves down along the spectrum of horror

and catastrophe. For example, because there is a qualitative difference

between being subjected to purposeful torture vs. motor vehicle accident

 even though both experiences may be associated with life threat, and

physical and psychological injury  vulnerability factors may be more

prominent in the case of a PTSD in response to the latter trauma. One

strategy for studying risk factors in the development of PTSD might be to

compare vulnerability factors in those experiencing high magnitude

responses to moderately severe to extremely severe traumatic events.

Prior victimization, particularly victimization in childhood, has

been found to be potent risk factor for the development of PTSD

following rape (10). Exposure to untoward events early in life might

also explain the development of other risks that have been identified,

such as those relating to personality characteristics and a history of

psychological or behavioral problems. Persons with avoidant or

antisocial personalities prior to the traumatic event have increased risk

for the development of PTSD (11), as do those with a history of

conduct disorder in childhood, and those with lower intelligence.

However, to a certain extent, these characteristics might also reflect adverse
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

4

YEHUDA

However, in addition to having a greater likelihood of developing PTSD

in response to life-threatening events (DSM-IV defined), adult children

of Holocaust survivors also appeared to develop PTSD symptoms in

response to events that the DSM-IV would not consider traumatic, but

that nonetheless, are extremely stressful, such as divorce, death in the

family, and other forms of separation (death of a therapist, loss of a

caretaker such as a nanny). Adult children were more likely to claim that

these events were more subjectively stressful to them than DSM-IV

traumatic events such as motor vehicle accidents, natural disasters, or

combat-related experiences. Interestingly, our preliminary data appear

to suggest that cortisol levels are just as low in offspring that indicate

being traumatized (i.e., developing PTSD symptoms) by a non-DSMIV event as they are by a DSM-IV traumatic event. 14

The data on the adult children of Holocaust survivors provide

an important insight into the relationship between vulnerability and

stressor severity. It may be that the development of PTSD following

less intense stressors is associated with greater individual vulnerability.

The logical extension of this argument is that sub-threshold traumatic

events  that is, events that might be considered too weak to produce

PTSD according to current DSM-IV definitions that include, for example,

potential life-threat  may produce PTSD-like syndromes in individuals

who are at increasing risk for the development of PTSD. Patients/

clients exhibiting exaggerated responses to environmental events may

not be exaggerating their pain, but rather may also be expressing

symptoms associated with pretraumatic vulnerability. Considerable care

should be taken to discuss possible pretraumatic stressful events or

other areas that might uncover vulnerability or risk. Dealing with the

multiplicity of factors that contribute to the response to an event, and

shoring up existing coping behaviors, might be particularly fruitful for

those who seem unduly burdened by traumatic events.

Vulnerability vs. Resilience

Although not all trauma survivors develop PTSD following

exposure to trauma, it is important to highlight recent prospective,

longitudinal studies which indicate that trauma survivors are just as

likely to develop other psychiatric disorders such as panic disorder and

depression post-trauma. Thus, PTSD is one type of response to trauma,

but exposure to trauma may be associated with many different types of

outcomes, including, not developing a psychiatric disorder.

But what about people who dont develop PTSD or any other

psychiatric disorder? Is it appropriate to consider those who do not

develop any psychiatric disorder  the less vulnerable trauma survivors

 stress-resistant? Perhaps yes. However, it seems clear that resistance

may be a characteristic that is malleable by traumatic experience. It is

certainly easy to see how an invulnerable individual may escape the fate

of posttraumatic symptoms the first and or even second time a traumatic

event occurs. But it may be that repeated exposure to stress causes an

erosion of resilience. Rather than considering the dichotomy between

resilience and vulnerability, it would be informative to consider the

relationship between these two constructs.

early life experiences. It is easy to see, for example, how abuse early in

life might lead to avoidance, sociopathy, conduct disorder and lower

intelligence as a reflection of (pre-) trauma-related cognitive

impairments.

Other risk factors for PTSD have emphasized a possible role

for a genetic diathesis towards PTSD. True and colleagues

demonstrated a greater prevalence of PTSD in the co-twin of

monozygotic trauma survivors who had a twin with PTSD compared

with dyzygotic twins of whom one twin had already developed PTSD

(12). These findings imply that the increased prevalence in monozygotic

twins is due to shared genes. Along these lines Davidson et al

demonstrated that trauma survivors with PTSD were more likely to

have parents and first-degree relatives with mood, anxiety, and

substance abuse disorders compared with trauma survivors who did

not develop PTSD (13). Our work has demonstrated that parental

PTSD might be a powerful risk factor for PTSD because children of

Holocaust survivors are more likely to develop PTSD in response to

traumatic events compared to a demographically-matched sample

whose parents were not Holocaust survivors (14).

The extent which any of these findings are indicative of truly

biological or genetic phenomena, as opposed to environmental

ones, is not yet clear because the vulnerability for PTSD in a trauma

survivor who has lived with a chronically, mentally ill family member

may reflect either genetics, experience, or some combination. For

example, children of Holocaust survivors report feeling chronically

stressed by hearing stories about the Holocaust, having to experience

their parents suffer chronic pain or having to care for their disabled

parents, feeling burdened by expectations of their parents, or

experiencing losses (like not having extended families or even

grandparents) as a result of the Holocaust. Thus, the increased

prevalence of PTSD in this group may reflect vulnerability owing to

experiential factors. Even if the diathesis were somehow biologically

transmitted to the children, the diathesis is still a consequence of the

traumatic stress in the parent. Thus, even the most biologic of

explanations for vulnerability must at some point deal with the fact

that a traumatic event has occurred. Therefore, rather than shifting the

focus away from the effects of the focal traumatic event, risk factors

justify why the effects of traumatic stress may be particularly devastating

and long-lasting for a strong contingency of trauma survivors.

Lessons from a High-Risk Group

For the last several years, our group at the Traumatic Stress

Studies Program at Mount Sinai School of Medicine and the Bronx

VA have been studying children of Holocaust survivors. Initially we

were intrigued by the fact that adult children of Holocaust survivors

appeared to have an elevated risk for the development of PTSD

following traumatic events (15). Furthermore, our data suggested

that the risk factor for these individuals was the presence of PTSD

in the parent. In one study we noted that PTSD in children of

Holocaust survivors was only present if the parent had PTSD, but

not if the survivor parent did not have chronic PTSD (16). Interestingly,

many of the adult children of Holocaust survivors seemed to show

evidence of low urinary cortisol excretion  similar to what our group

has described in chronic PTSD (17).
Volume 8 (1) Winter 1998

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NC-PTSD Clinical Quarterly

RESILIENCE AND VULNERABILITY FACTORS

References

1. Yehuda, R., & McFarlane, A.C. (1995). Conflict between current

knowledge about posttraumatic stress disorder and its original

conceptual basis. American Journal of Psychiatry, 152, 1705-

1713.

2. Southwick, S.M., Krystal, J.H., Johnson, D.R., & Charney, D.S.

(1995). Neurobiology of posttraumatic stress disorder. In G.

Everly & J. Lating (Ed.), Psychotraumatology: Key papers and

core concepts in post-traumatic stress. New York: Plenum Press.

3. Yehuda, R., Shalev, A.Y., McFarlane, A.C. (in press). Predicting the

development of posttraumatic stress disorder from the acute

response to traumatic event. Biological Psychiatry.

4. Yehuda, R. (1998). Neuroendocrinology of Trauma and PTSD. In

R. Yehuda (Ed.), Psychological trauma. Annual Review of

Psychiatry, 17, Washington, DC: American Psychiatric

Association Press.

5. Breslau, N., Kessler, R.C., & Chilcoat, H.D. (1998). Trauma and

posttraumatic stress disorder in the community. Archives of

General Psychiatry, 55, 626-632.

6. Kessler, R.C., Sonnega, A., Bromet, E., & Nelson, C.B. (1995).

Posttraumatic stress disorder in the National Comorbidity

Survey. Archives of General Psychiatry, 52, 1048-1060.

7. Goldstein, G., vanKammen, W., Shelly, C., Miller, D.J., & van

Kammen, D.P. (1987). Survivors of imprisonment in the Pacific

theater during World War II. American Journal of Psychiatry,

144, 1210-1213.

8. Yehuda, R., Kahana, B., Schmeidler, J., Southwick, S.M., Wilson, S.,

& Giller, E.L. (1995). The impact of cumulative lifetime trauma

and recent stress on current posttraumatic stress disorder

symptoms in Holocaust survivors. American Journal of

Psychiatry, 152, 1815-1818.

9. Shore, J.H., Tatum, E.L., & Vollmer, V.M. (1986). Psychiatric reaction

to disaster: The Mount St. Helens experience.American Journal

of Psychiatry, 143, 590-595.

10. Resnick, H.S., Kilpatrick, D.G., Best, C.L., & Kramer, T.L. (1992).

Vulnerability stress factors in the development of posttraumatic

stress disorder. Journal of Nervous and Mental Disorders,

180, 424-430.

11. Schnurr, P.P., Friedman, M.J., & Rosenberg, S.D. (1993). Preliminary

MMPI scores as predictors of combat-related PTSD

symptoms. American Journal of Psychiatry, 150, 479-483.

12. True, W.R., Rise, J., Eisen, S., Heath, A.C., Goldberg, J., Lyons, M.,

& Nowak, J. (1993). A twin study of genetic and environmental

contributions to liability for posttraumatic stress symptoms.

Archives of General Psychiatry, 50, 257-264.

13. Davidson, J., Swartz, M., Storck, M., Krishnan, R., & Hammett, E.

(1985). A diagnostic and family study of posttraumatic stress

disorder. American Journal of Psychiatry, 142, 90-93.

14. Yehuda, R., Schmeidler, J., Wainberg, M., Binder-Brynes, K., &

Duvdevani, T. (1998). Increased vulnerability to posttraumatic

stress disorder in adult offspring of Holocaust survivors.

American Journal of Psychiatry, 155, 1163-1172.

15. Yehuda, R., Schmeidler, J., Giller, E.L., & Siever, L.J. (1998).

Relationship between PTSD characteristics of Holocaust

survivors and their adult offspring. American Journal of

Psychiatry, 155, 841-843.

16. Yehuda, R. (in press). Parental PTSD as a risk factor for PTSD. In

R. Yehuda (Ed.), Risk factors for posttraumatic stress disorder.

Washington, DC: American Psychiatric Association, Inc.

17. Yehuda, R., Schmeidler, J., Elkin, A., Siever, L., Binder-Brynes, K.,

Wainberg, M., & Aferiot, D. (1998). Phenomenology and

psychobiology of the intergenerational response to trauma. In

Y. Danieli (Ed.), Intergenerational handbook: Multigenerational

legacies of trauma. New York: Plenum Press.

Rachel Yehuda, Ph.D. is professor of Psychiatry and Director of Traumatic

Stress Studies Program at the Mount Sinai School of Medicine and the

Bronx VA Medical Center. She is the author over 100 scientific publications

on various topics in PTSD and three books: Psychobiology of Posttraumatic

Stress Disorder, Psychological Trauma, and Risk Factors for Posttraumatic

Stress Disorder.
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

6

Demands on health care providers to

demonstrate effective treatment has led to recent

emphasis on psychometric instruments designed

to quantify improvements in mental health

patients. However, the symptomatology

accompanying chronic, combat-related PTSD is

extremely complex and it is difficult to identify or

target specific symptoms with which to measure

change. Determining what, how, and when to

measure has been a great challenge in research on

chronic PTSD (e.g., 1, 2).

What To Measure

It seems self-evident that the diagnosis of PTSD would be

a central feature of research on the course of PTSD. However,

determining that an individual does or does not experience

symptoms of sufficient severity to meet diagnostic criteria is often

not meaningful in chronic PTSD. In severe cases, a PTSD diagnosis

may be maintained even when symptoms abate substantially. In

less severe cases, an individuals symptom levels may hover around

diagnostic cutoffs, falling below at one point and above at another.

In these cases, use of a dichotomous diagnosis variable to represent

PTSD can allow minor fluctuations in symptoms to appear greater

than they really are.

Measuring the number and severity of PTSD symptoms

and how they fluctuate over time allows for a more sensitive

examination of changes. However, even when the units of

measurement are quite refined, PTSD symptoms may not change

substantially in the chronic phase of this disorder (2, 3). Comorbid

psychopathology, related symptomatology, and quality of life

assessment may provide better information about change.

Comorbid disorders, especially depression and substance abuse,

are pervasive in the veteran PTSD population (4-6) and should be

assessed to illustrate a full picture of symptomatology. As will be

illustrated below in the case of Mr. Z, it can be very challenging to

determine the relative importance of various symptoms when an

individual presents a mottled pattern of strengths and difficulties.

Assessment of the event or events that make up Criterion

A for a PTSD diagnosis is also often very complicated. When

individuals have experienced multiple potentially traumatic events,

it can be difficult to decide which or how many of them contribute

to the post-trauma symptomatology. For example, in the case of

combat-related PTSD, warzone experiences are considered the index

events, yet many veterans suffered traumatic experiences both before

and subsequent to their military traumas. These additional

experiences are likely to have contributed to current symptomatology,

yet it can be difficult or impossible to determine their relative

influence on current functioning. In addition, the relative importance

of several Criterion A events may change over time: a person may be

bothered by intrusive memories of a certain event for a period of time,

while at another time, a different event may be most salient and intrusive.

How To Measure

As with other psychiatric disorders, the most common method

of gathering information about PTSD is to ask the individual about

his or her symptoms. This can be done using pencil-and-paper selfreport checklists or structured interviews. Family members ratings of

symptoms provide additional useful information which can be

compared to the ratings provided by the individual under study.

Assessment of physiological reactivity to trauma-related stimuli is also

a good source of data. Advantages and drawbacks of each of these

methods are briefly discussed below.

Self-report scales. Several valid and reliable self-report checklists have

been developed to assess PTSD symptoms, and some assess related

symptomatology as well. For example, in the case of Mr. Z, the 35-

item Mississippi Scale for Combat-Related PTSD (7), the PTSD

subscales (8, 9) of the Minnesota Multiphasic Personality Inventory

(MMPI; 10), and the MMPI-2 (11) were used to assess symptoms.

These scales have been widely-used in the assessment of combat-related

PTSD and have performed as well as self-report measures of the

disorder (12, 13).

An advantage of self-report assessment measures is that they

are cost-efficient and do not require clinician time for administration.

In addition, the ratings are not influenced by potential clinical bias.

However, an important shortcoming of these instruments is that scores

of PTSD severity do not indicate if the information provided is accurate.

An individual may exaggerate or underestimate ratings, misunderstand

the questions, or respond randomly on the questionnaire. The MMPI2 (11) has some useful validity scales that can alert clinicians to several

of these issues (e.g. 14-15). Even when the information provided by

these scales is considered, however, it is often not possible to clearly

understand the various potential factors that may influence the

individuals reporting style.

THERAPEUTIC FOLLOW-UP IN CHRONIC

PTSD: THE CHALLENGES OF MEASUREMENT

Barbara L. Niles, Ph.D., Elana Newman, Ph.D., and Lisa M. Fisher, Ph.D.

 Barbara L. Niles, Ph.D. Elana Newman, Ph.D. Lisa M. Fisher, Ph.D.
Volume 8 (1) Winter 1998

7

NC-PTSD Clinical Quarterly

continued on page 8

Assessment interviews. Clinician-administered structured or semistructured interviews have also been widely used for assessment. Two

commonly-used instruments of this type, the Structured Clinical

Interview for DSM-III-R diagnosis (16) and the Clinician-Administered

PTSD Scale (17), were used in the assessment of Mr. Z. In such an

interview, a clinician can ensure that all symptomatology is reviewed in

detail while also allowing interviewees to describe their symptoms in

their own words (18). The clinician can use both verbal and nonverbal

information to evaluate whether the interviewee understands the

questions or is responding randomly and can guide the interview

accordingly. In addition, a skilled clinician can often detect when an

interviewee is overstating or understating symptoms. However,

clinician judgment can also be biased or inaccurate.

Collateral reports. Reports from partners, family members, or friends

can also provide valuable data in clinical assessment. Collateral

assessment of PTSD can bypass some of the obstacles to accurate selfreporting, such as denial, reading comprehension problems, avoidance,

or amnesia. However, collateral information is often not accessible to

the assessor: when it is, it is also subject to influence from biases and

response sets.

Psychophyisological assessment. Measurement of physiological

reactivity to exposure to cues of the traumatic event can offer important

additional information in a comprehensive assessment. Substantial

increases in heart rate, blood pressure, muscle tension, and skin

conductance in response to cues are evidence of increased physiological

reactivity and can confirm a diagnosis of PTSD. These measures do

not rely on either self-report or clinician judgment, and therefore the

impact of response sets or biases is minimized. However,

psychophsiological reactivity is considered an indicator of PTSD, not a

definitive measure. These assessments have good specificity, but the

sensitivity is low (19). Reactivity can be influenced by many outside

factors, such as psychotropic and antihypertensive medications. In

addition, in many outpatient settings, the resources necessary for such

assessments are not available.

All of the measures described above can provide meaningful

information in an assessment, but each has some degree of error. The

importance of combining data derived from self-report interviews,

structured clinical interviews, and, when possible, psychophysiological

assessment and collateral reports into a comprehensive mulitmodal

assessment has been greatly emphasized in the literature on evaluation

of PTSD (e.g., 20-23). When multiple measures are used, the strengths

of some can compensate for the shortcomings of others.

When To Measure

Clinical observations and a limited number of empirical studies

have demonstrated that chronic PTSD is both persistent and fluctuating.

The striking persistence of PTSD symptoms has been widely discussed

in clinical literature, particularly with regard to combat veterans, in

descriptive accounts (e.g., 24-25), and in the emerging treatment outcome

literature (e.g., 2, 26). In the comprehensive National Vietnam Veterans

Readjustment Study (NVVRS; 12), about half of the Vietnam veterans

who ever met diagnostic criteria for PTSD were also diagnosed with

this disorder when they were assessed in the late 1980s. The remarkable

chronic nature and severity of PTSD in Vietnam veterans seeking

inpatient VA PTSD treatment has led Shalev (2) to suggest that longstanding combat-related PTSD in Vietnam veterans may be treatment

resistant in many cases. In all, these findings support the

conceptualization of PTSD as a chronic, unremitting disorder.

However, there is also compelling evidence for fluctuation in

symptoms of PTSD. The other half of the veterans in the NVVRS

who were diagnosed as having had PTSD in their lifetimes reported

that their PTSD symptoms had decreased enough so that full diagnostic

criteria for PTSD were no longer met (12), suggesting that at least

some symptoms remit over time.

Measuring the number and severity of

PTSD symptoms and how they fluctuate over

time allows for a more sensitive examination

of changes. However, even when the units of

measurement are quite refined, PTSD

symptoms may not change substantially in

the chronic phase of this disorder.

Other research has indicated that PTSD symptoms in combat

veterans can be reactivated after periods of relative dormancy. Life

stressors, such as retirement, death of a parent, or children leaving

home, have precipitated PTSD symptoms in World War II combat

veterans (25). Visits to war memorials and other public ceremonies

that were reminders of combat have been reported to exacerbate

symptomatology in Vietnam veterans (26). Solomon (27) described

the ways that the 1982 Lebanon War reactivated symptoms in Israeli

combat veterans of the 1973 Yom Kippur War. Because the little we

know about the course of chronic PTSD indicates that it fluctuates,

persists, and can be reactivated, it is unclear when to measure so that

substantive changes over time can be detected.

A Case Study: Mr. Z

Case studies can provide a fund of information about the course

of PTSD, what influences it, and the ways in which people change.

Detailed analyses of individual cases can illustrate the challenges to

accurate assessment of changes in chronic PTSD and guide us in

determining methods of evaluation that will adequately represent how

and why people change.

Mr. Z is one of the veterans who took part in a follow-up study

of Vietnam veterans who were evaluated in the late 1980s at the Boston

VA PTSD clinic. He sought treatment and received an extensive

multimodal evaluation for combat-related PTSD in 1988 (Time One).

He was recontacted six years later (Time Two) and agreed to participate

in a follow-up evaluation for research purposes.
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

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Time One

Mr. Z was initially referred for a PTSD evaluation from the

inpatient substance abuse unit where he was being treated for heroin

addiction. He completed the seven sessions of the time one evaluation

as an outpatient and pursued further therapeutic services at its

completion. At the time one evaluation, a thorough history was taken,

diagnostic interviews were done, and Mr. Z completed self-report measures.

History. Mr. Z grew up as the third of five children in an IrishAmerican family where both parents worked as laborers in a large

company. He described his home life as generally chaotic, with extensive

physical abuse by his father that occasionally resulted in hospitalizations

due to injuries. His mother was an alcoholic and was generally

unavailable to the children. Mr. Z acted as a protector for his younger

siblings, especially after his older brother enlisted in the Marine Corps

in order to get out of the home.

Despite the situation at home, Mr. Z showed impressive

resiliency. He did well in school until high school, when he began

working regularly to help support the family. The distractions of work

caused his grades to drop, and he was required to repeat grade 12.

However he reported that he felt good about his ability to work and

about his success in helping to provide for his family. He reported

good relations with peers and was active in sports and other activities

as much as his work schedule would allow. He had no legal infractions.

There were some signs of difficulty, however: Mr. Z began to use

alcohol extensively, up to 12 beers per week-end night, just before he

entered the military.

Just after completing high school, Mr. Z enlisted in the Marine

Corps, following his older brothers footsteps. Mr. Z was sent to

Vietnam for one 13-month tour. He served as a helicopter door gunner

in a unit that performed extractions of soldiers in the field, assaults on

the enemy, and defoliation of jungle areas through spraying of Agent

Orange.

Harrowing combat experiences were frequent during Mr. Zs

tour. For example, he reported being shot down and then rescued by

other helicopters on several occasions, and he recounted that his gun

jammed while in the midst of fire fights with the enemy. He also

reported that he felt pride in his ability to perform his duties well under

these circumstances. Between these missions, while stationed at a

secure fire base, Mr. Z had a fair amount of leisure time and was able to

use alcohol and intravenous opium extensively without significantly

compromising his or his units safety.

After discharge, Mr. Z continued to use drugs extensively and

became addicted to heroin. In order to support his habit, he became

involved in selling drugs. He also worked at various jobs as a

construction laborer, but was never able to hold any job for more than

a few months because of his substance use problems. He was convicted

of various legal infractions related to drug-selling and possession, and

served a few short prison sentences totaling about two years.

Throughout the 1970s and up until his time one evaluation, Mr. Z

was firmly entrenched in the drug world. His friends, girlfriends,

and family members were all heavy substance users.

Diagnoses and symptomatology. As Table One indicates, Mr.

Z did not meet diagnostic criteria for PTSD at Time One as assessed by

structured interview (SCID). Although he clearly met Criterion A

(exposure to a recognizable stressor), he did not have sufficient reMr. Z attributed his success to lessons learned during the yearof PTSD-focused individual therapy that followed his Time One

Psychometric measures. Both the Mississippi Scale and the

MMPI subscale fall below established cut-offs for PTSD. This is

consistent with interview data suggesting that he did not meet criteria

for PTSD. The combat exposure scale (CES) indicates moderate

exposure to combat. The Beck Depression Inventory (BDI) provides

another indicator that he was not suffering from depression at Time

One.

Time Two

History. The striking change for this veteran was that he stopped

using illegal drugs and extracted himself from drug-using and selling

scene. Mr. Z reported that he had a few slips and one major relapse

to using heroin since his Time One evaluation, but at his Time Two

evaluation he had abstained from heroin for more than four years. In

terms of occupational and interpersonal functioning, things had

improved substantially since the first evaluation. He was self-employed

and working full-time and reported a positive relationship with his

girlfriend of several years with whom he lived.

Table 1

VARIABLE TIME ONE TIME TWO

PTSD Diagnosis no yes

Comorbid Axis I Diagnoses polysubstance alcohol

 dependence dependence, mild

Mississippi Scale 94 73

MMPI-2 PK scale 13 16

Combat Exposure Scale (CES) 23 20

Violent Behaviors/ Past Year 1 0

Fear of losing control (1-5 scale) 3.5 1

experiencing symptoms to meet Criterion B. He reported occasional

thoughts and dreams about his Vietnam experiences, but

reportedthat he did not find these recollections to be upsetting. He

did meet Criterion C (numbing and avoidance) as he felt emotionally

numb and had a sense of foreshortened future, but it was unclear if

this disinterest in relationships and activities was related more to his

substance use or to his traumatic war experiences. It was difficult for

the assessing clinician to distinguish because at time one he reported

that he cared about little else besides getting high. He also reported

some Criterion D arousal symptoms at time one, but he medicated

these with drug use, so it was difficult to discern their intensity and

severity.

In terms of comorbid disorders, Mr. Z was diagnosed with

polysubstance abuse, but was not suffering from depression. Violent

behavior over the past year was assessed by clinician questioning. Mr. Z

reported few episodes of violent behavior, but reported concern about

his ability to maintain control when angered.

NILES, NEWMAN, & FISHER
Volume 8 (1) Winter 1998

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NC-PTSD Clinical Quarterly

Consideration of the life context in which the index traumatic

events take place is a vital part of a thorough PTSD evaluation. Coping

strategies and other traumatic events were important factors affecting

functioning in the case of Mr. Z. For the purposes of this evaluation,

Mr. Zs post-trauma symptoms were indexed to his Vietnam experiences,

but he also reported pre-military traumatic events that appeared to have

affected his functioning and symptomatology as well. His experiences in

Vietnam clearly exacerbated existing problems: he had begun to employ

the maladaptive coping strategy of substance use prior to entry into the

military, but his use increased dramatically in and after Vietnam. On the

other hand, some of the positive coping strategies he maintains were

also in place prior to his military service. His strong work ethic and the

sense of esteem derived from work have helped him combat his PTSD

symptoms.

How to measure. As stated above, it is extremely important to

consider an individuals style of endorsement of symptoms in

interpretation of psychometric results. Mr. Zs tendency to minimize

his symptoms on the psychometrics at Time Two made it more difficult

to discern how his symptoms had changed. Mr. Zs admission that he

was minimizing his symptoms permitted a more accurate interpretation

of the psychometric instruments.

When to measure. Mr. Z reported that he was not in the midst

of one of his anniversary periods at the Time Two assessment. It is

unclear whether or not he was experiencing an anniversary reaction at

Time One as this was not directly assessed. If important anniversaries

had been assessed at Time One, it might have helped determine how

representative his symptoms were at assessment. However, it is also

quite likely that Mr. Z would have been unaware of his anniversary

periods prior to therapy, and might not have been able to provide accurate

information about them.

Summary

Understanding what, how, and when to measure PTSD is critical

in order to accurately assess progression, outcome, or remission of this

disorder. The diagnosis of PTSD alone is insufficient to reflect the

subtleties of this multifaceted problem. Multimodal assessments at

multiple points in time are needed in order to understand the various

components of an individuals manifestation of PTSD symptoms.

References

1. Bleich, A., Shalev, A., Shoham, S., Solomon, Z., & Kotler, M. (1992).

PTSD: Theoretical and practical considerations as reflected through

Koach_an innovative treatment program. Journal of Traumatic

Stress, 5, 265-271.

2. Shalev, A. (1997). Discussion: Treatment of prolonged Posttraumatic

Stress Disorder_learning from experience. Journal of Traumatic

Stress, 10, 415-423.

3. Johnson, D.R. (1997). Introduction: Inside the specialized inpatient

PTSD units of the Department of Veterans Affairs. Journal of

Traumatic Stress, 10, 357-360.

4. Keane, T.M., & Kaloupek, D.G. (1997). Psychiatric Disorders in PTSD:

Implications for research. In R. Yehuda & A.C. McFarlane (Eds.),

Psychobiology of Post Traumatic Stress Disorder (pp. 24-34).

Annals of the new York Academy of Sciences.

THERAPEUTIC FOLLOW-UP IN CHRONIC PTSD

evaluation. Specifically, he reported that he learned to confront rather

than avoid problems in general, and to confront distressing memories

of traumatic life events in particular. He learned to face his problems,

rather than attempting to escape from them by using drugs. He did

continue to use alcohol, drinking three to six beers per night, but

this was a large reduction from his former levels of use. Mr. Z

reported feeling in more control of violent impulses and reported

no violent behaviors in the past year.

Diagnoses and symptomatology. At Time Two, the CAPS

structured interview indicated that Mr. Z met diagnostic criteria for

PTSD. His intrusive thoughts and dreams were frequent and

upsetting to him, so he clearly met Criterion B. His avoidance and

numbing was more clearly trauma-related (as opposed to drugrelated), so he also met Criterion C. And his physiological reactivity

was of sufficient frequency and intensity to meet Criterion D. His

polysubstance abuse was in remission, although he did meet

diagnosis for mild alcohol dependence.

Mr. Z described that every year he experienced an anniversary

reaction to one of his most salient Vietnam traumas. He recognized

that he tended to drink more and isolate more during these times.

But he stated that he was gaining confidence in dealing with these

episodes because he was able to anticipate them and had learned

much about how to cope with them by being in therapy.

Psychometric measures. At Time Two, Mr. Zs Mississippi

Scale and MMPI subscale were also below established cut-offs for

PTSD. His Mississippi Scale went down substantially, although the

MMPI subscale went up. This may reflect that Mr. Z was minimizing

his symptoms at Time Two in order to appear to be functioning

better. During debriefing after the Time Two assessment, Mr. Z

reported that he had wanted to show us how he had improved

during the interim since Time One. He reported that he did this as

a way of thanking us for the services he received and letting us know

that our services were well used and effective. Thus, we surmised

that he probably under-endorsed on the Mississippi Scale, an

instrument with high face validity. The MMPI subscale, showing an

increase in symptomatology, is less obviously related to PTSD

symptomatology, and is probably a more accurate indication of his

symptoms at Time Two.

Points of Interest

What to measure. In this case, a focus on PTSD diagnosis or

PTSD symptoms only would indicate that this veterans functioning

declined. Yet this veteran himself and most objective opinions of

his overall functioning would indicate vast improvement in

functioning. Thus it is important to note that PTSD symptoms

may worsen, even when general functioning improves.

Substance use is the most likely explanation for the disparity

between Mr. Zs overall functioning and the scores on the PTSD

measures. He was self-medicating and suppressing his PTSD

symptoms with opiates prior to Time One. Substance use disorders

can often obscure the clinical picture in patients with PTSD, and the

PTSD symptoms may not emerge until a substantial period of

sobriety has been achieved. Psychoactive substance use may be so

effective at numbing the symptoms of PTSD that they are undetectable

to both the client and the clinicians working with him or her.
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

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19. Gerardi, R., Keane, T.M., & Penk, W. (1989). Utility: Sensitivity and

specificity in developing diagnostic tests of combat-related posttraumatic stress disorder. Journal of Clinical Psychology, 45,

691-703.

20. Keane, T.M., Newman, E., & Orsillo, S.M. (1997). The assessment

of military-related PTSD. In J. Wilson & T. Keane (Eds.)

Assessing psychological trauma and PTSD: A handbook for

practitioners. New York: Guilford Press.

21. Keane, T.M., Wolfe, J., & Taylor, K.L. (1987). Post-traumatic stress

disorder: Evidence for diagnostic validity and methods of

psychological assessment. Journal of Clinical Psychology, 43,

32-43.

22. Horowitz, M. (1986). Stress Response Syndromes (2nd Edition).

New York: Jason Aronson.

23. Horowitz, M.J. (1993). Stress response syndromes: A review of

posttraumatic stress and adjustment disorders. In J.P. Wilson

and B. Raphael (Eds.), International handbook of traumatic

stress syndromes (pp 49-60). New York: Plenum.

24. Johnson, D., Rosenheck, R. Fontana, A., Lubin, H., Southwick, S.

& Charney, D. (1996). Outcome of intensive inpatient treatment

for combat-related PTSD. American Journal of Psychiatry, 153,

771-777.

25. Christenson, R.M., Walker, J.I., Ross, D.R., Maltbie, A. (1981).

Reactivation of traumatic conflicts. American Journal of

Psychiatry, 138, 984-985.

26. Faltas, F.J., Sirota, A.D., Parsons, S.J., Daamen, M., & Schare, M.L.

(1986). Exacerbations of post-traumatic stress disorder

symptomatology in Vietnam Veterans. Military Medicine, 152,

12, 648-649.

27. Solomon, Z. (1993). Combat stress reaction: The enduring toll of

war. New York: Plenum.

Acknowledgments: We want to express our appreciation for the contributions

of Danny Kaloupek, Ph.D., and Terence M. Keane, Ph.D., who provided the

Time One data set and financial, scientific, and editorial support for this

project. We also thank Melissa S. Covington for her help in preparing this

manuscript.

5. Keane, T.M., & Wolfe, J. (1990). Comorbidity in post-traumatic

stress disorder: An analysis of community and clinical studies.

Journal of Applied Social Psychology, 20, 1776-1788.

6. Sierles, F.S., Chen, J., Messing, M.L., Besyner, J.K., & Taylor, M.A.

(1986). Concurrent psychiatric illness in non-Hispanic outpatients

diagnosed as having posttraumatic stress disorder. Journal of

Nervous and Mental Disease, 174, 171-173.

7. Keane, T.M., Caddell, J.M., & Taylor, K.I. (1988). Mississippi scale

for Combat-Related Posttraumatic Stress Disorder: Three

studies in reliability and validity. Journal of Consulting and

Clinical Psychology, 56, 85-90.

8. Keane, T.M., Malloy, P.F., & Fairbank, J.A. (1984). Empirical

development of an MMPI subscale for the assessment of

combat-related posttraumatic stress disorder. Journal of

Consulting and Clinical Psychology, 52, 888-891.

9. Lyons, J.A., & Keane, T.M. (1992). Keane PTSD Scale: MMPI and

MMPI-2 update. Journal of Traumatic Stress, 5, 111-117.

10. Hathaway, S.R. & McKinley, J.C. (1943). The Minnesota Multiphasic

Personality Inventory. Minneapolis, MN: University of

Minnesota Press.

11. Butcher, J.N., Dahlstrom, W.G., Graham, J.R., Tellegen, A., &

Kaemer, B. (1989). MMPI-2: Manual for administration and

scoring. Minneapolis, MN: University of Minnesota Press.

12. Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Jordan, B. K., Hough,

R.I., Marmar, C.R., & Weiss, D.S. (1990). Trauma and the

Vietnam War generation: Report of findings from the National

Vietnam Veterans Readjustment Study. New York : Brunner/

Mazel.

13. Kulka, R. A., Schlenger, W. E., Fairbank, J.A., Jordan, B.K., Hough,

R.I., Marmar, C.R., & Weiss, D.S. (1991). Assessment of posttraumatic stress disorder in the community: Prospects and pitfalls from recent studies of Vietnam veterans. Psychological

Assessment: A Journal of Consulting and Clinical Psychology,

3, 547-560.

14. Arbisi, P.A. & Ben-Porath, Y.S. (1995). An MMPI-2 infrequent

response scale for use with psychopathological populations:

The infrequency-psychopathology scale, F(p). Psychological

Assessment, 7, 424-431. Barbara L. Niles, Ph.D. is a staff psychologist in the Behavioral Sciences

Division of the NC-PTSD at the Boston VAMC and an Instructor in the

Department of Psychiatry at Tufts Univ.ersity School of Medicine. The emphasis

of her clinical work and research has been in the area of combat-related PTSD

in veterans. Her recent work has been focused on the longitudinal course of this

disorder.

Elana Newman, Ph.D. is currently an Assistant Professor in the Department of

Psychology at the University of Tulsa in Oklahoma. She collaborated on this

follow-up study when she was a postdoctoral fellow at the Behavioral Sciences

Division of the NC-PTSD in Boston. Her research has focused on traumarelated assessment and ethics in trauma research.

Lisa Fisher, Ph.D. is Associate Director of Clinical Programs, Behavioral Sciences Division of the NC-PTSD at the Boston VAMC and Assistant Professor

in the Department of Psychiatry at Tufts Univ.ersity School of Medicine. Her

clinical interests include PTSD treatment program development, clinical outcome,

and secondary PTSD.

THERAPEUTIC FOLLOW-UP IN CHRONIC PTSD

15. Butcher, J.N., Grahm, J.R., Williams, C.L., & Ben-Porath, Y.S. (1990).

Development and use of the MMPI-2 content scales.

Minneapolis,MN: University of Minnesota Press.

16. Spitzer, R.L., Williams, J.B., Gibbons, M., & First, M.B. (1990).

Structural Clinical Interview for DSM-III-R - Patient Edition

(SCID -P, Version 1.0). Washington, DC: American Psychiatric

Press.

17. Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G.,

Klauminzer, G., Charney, D.S., & Keane, T.M. (1990). A clinician

rating scale for assessing current and lifetime PTSD: The CAPS1. The Behavior Therapist, 18, 187-188.

18. Newman, E., Kaloupek, D.G., & Keane, T.M. (1996). Assessment

of posttraumatic stress disorder in clinical and research settings.

In B. van der Kolk, A.C. McFarlane, & L. Weisaeth (Eds.),

Comprehensive text on post-traumatic stress (pp. 242-275).

New York: Guilford Press.
Volume 8 (1) Winter 1998

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NC-PTSD Clinical Quarterly

Many of you have been working with trauma survivors for a long time.  Those of us who cut our professional teeth in

the VA health care system during the 1970s have now been treating veterans with war-zone-related PTSD for more than two

decades. Remarkable advances have been made during this time. PTSD was first recognized as a diagnosis in the DSM-III in

1980. Clinical programs in VA Medical Centers, Vet Centers, military front echelon units, civilian rape crisis centers, civilian

inpatient/outpatient programs, and most disaster relief settings have multiplied to such an extent that they have become a hardwired component of many comprehensive health care systems. Research on traumatic stress has shown that fundamental

psychological and neurobiological systems are altered in PTSD and brain imaging studies have provided preliminary data suggesting

that basic cognitive operations such as perception, learning and memory may be different in people with PTSD. Finally, PTSD

is no longer invisible to the lay public or to the media who serve them. Thoughtful articles and broadcasts on the consequences

of trauma appear with regularity and are readily understood by a public that has grown increasingly sophisticated in this regard.  

As we take stock of all this remarkable progress, it is easy to forget how much farther we need to go. HMO-driven

changes in American health care have shrunk the 7% allocated to mental health in the late 1980s to 3.5% in 1996. Comprehensive

health care legislation initiatives introduced into the US Congress have frequently treated mental health benefits as a lower

priority than medical/surgical coverage. This has been possible because of the continuing stigma that undervalues mental health

treatment in contrast to real medical (e.g., medical/surgical) programs.  Indeed, the recent congressional effort to obtain

parity for mental health benefits was necessitated because HMOs and insurance companies had consistently short-changed

mental health benefits and because the social and political climate had enabled them to get away with such a policy for years. 

My concern is that as needed cost-effective measures are instituted in an era of government downsizing and shrinking

resources, mental health programs will not have an equal opportunity to make their case.  There may not be a level playing field

on which mental health can compete with medicine, surgery, radiology, etc. for its fair share of the health care dollar.  With

respect to PTSD, it appears to be a particularly dangerous time for such a young field to try to establish its niche in the spectrum

of essential health care programs. There is still a myth in many circles that PTSD is just about Vietnam veterans and that theyve

already had their share of resources. This myth is perpetuated by people who do not know or refuse to acknowledge that

PTSD is a major public health problem that affects 10% of all American women and 5% of all American men. Perpetuation of

this myth threatens to suppress the growth of the trauma field prematurely, thereby depriving millions of military, veteran and

civilian individuals of the preventive and therapeutic advances that finally seem within our grasp.  

We cannot continue to conduct clinical business as usual. We cannot assume that influential people will notice and want to

preserve either the excellent clinical care we provide our patients with PTSD or the groundbreaking discoveries shown by

research on the psychological and neurobiological  consequences of traumatic stress. It is our job to help them see, understand, and

appreciate all that we have accomplished in less than 20 short years. It is even more important that we help them see, understand,

and appreciate all that has not been done and must yet be done if we are to realize the potential of our powerful new conceptual

and clinical tools.  

We are just beginning to test and refine cognitive-behavioral and other psychotherapeutic approaches, new drugs designed

specifically for PTSD, strategies to identify risk-factors in PTSD-vulnerable people, preventive measures designed to reduce the

deleterious impact of childhood trauma and domestic violence, and acute interventions to forestall the development of PTSD

among military, police, emergency medical and disaster relief professionals, as well as among the survivors of war trauma,

sexual assault, interpersonal/domestic/urban violence, motor vehicle accidents, and natural disasters. These efforts must not be

curtailed.  I think we all have an important opportunity and obligation to show people what we can do now and might accomplish in

the future. It is a massive educational commitment that we dare not refuse to make. I hope you will join me in this effort.  

 NEW DIRECTIONS Matthew J. Friedman. M.D., Ph.D.

 Executive Director, NC-PTSD
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

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WOMEN AND TRAUMA: A CLINICAL FORUM

Marylene Cloitre, Ph.D.

This issues guest author is Karestan C. Koenen, a graduate student in the clinical psychology program at Boston University

and a psychology fellow at the Payne Whitney Clinic of New York Hospital. She is currently principle investigator on a grant entitled

"The Comorbidity of PTSD and Antisocial Personality Disorder" funded by the Department of Veteran's Affairs and a recipient of

a National Research Service Award from NIH.

As a trainee, I have had the opportunity to work in several different settings that focus on treating and researching trauma and PTSD.

During these experiences, other students and I would discuss issues we viewed as important in our training. In this column, I discuss several

of the issues that have been raised by students. It is my hope these concerns will be considered by clinical training directors when planning and

implementing their programs.

1. How might trauma impact a therapist?

I went to a party last night and someone asked me what I do for a living. When I told her I treated women sexually abused as children, she said, Thats

terrible. Why would you want to do something so depressing? and then she walked away. -Psychology Intern

In this example, the intern encounters what might be the conventional wisdom about the risks of getting to close to another persons

suffering and perhaps senses the social isolation associated with being perceived as a contagion. Working with traumatized individuals can even

leave a therapist feeling alone, disillusioned, and frightened. Several authors have explained these types of reactions as an effect of secondary

exposure or vicarious traumatization. Such traumatization is evident when a therapist caring for a victim of crime, sexual abuse, disaster, or

combat develops a post-traumatic like reaction from hearing about the traumatic incident and seeing its effect on their patient (1-5).

I have had heard many clinical and research trainees talk about having been surprised by their intense emotional reactions after vicarious

exposure to traumatic material. It is not uncommon to hear descriptions about having become hypervigilent and anxious, or about experiencing

mild sleep difficulties and feelings of anger about the injustices in the world. Some students describe functional difficulties, such as withdrawing

socially from their peers. They noted that the people whom they typically depend on for support were unable to understand the difficulties

associated with working with traumatized clients.

However, students whose supervisors prepared them for the possible difficulties of working with traumatized individuals report greater

confidence and ability to maintain emotional equilibrium. This preparation included helping them anticipate possible reactions before meeting

with clients, having regular post-intervention discussions of the traumatic material with the supervisor, and ongoing clinical supervision. The

scope of such supervision could additionally benefit research technicians and assistants who interview patients or who are involved with the

transcription of trauma narratives recorded on audio/video tapes for research projects.

Throughout my training, I have sought the advice and wisdom from various senior clinicians about the challenges of working with

trauma survivors. From them I have learned the importance of being very attentive to my appointment schedule. Toward this end, I have seen

the importance of not clustering multiple appointments together without giving myself time to relax, debrief with others, or take a walk in

between client meetings. I have also come to value maintaining a healthy lifestyle through diet, exercise, and enjoyable activities.

The most important piece of advice I received is learning to monitor and appreciate my limitations. As a trainee, I know the many

demands on my time that exist  dissertation, professional meetings, social obligations, etc. If I begin to feel overwhelmed while treating

clients, I know that I must make some adjustments so that I can be more emotionally available for my patients. Finally, I have come to realize

that the social support I receive from other trainees in the field is essential. As student coordinator for the International Society for Traumatic

Stress Studies (ISTSS), I try to encourage other trainees to seek support from their peer groups. Student members of ISTSS now routinely use

email as one source of support with other students they have met at conferences or through our directory to feel connected to a larger network

of trainees.

2. Avoiding talking about the trauma

She first said she sought treatment because of symptoms related to having been raped but she hasnt brought it up since our first session. Maybe shes not

ready to talk about it. I dont want to pressure her.- Practicum student

For both the client and the therapist, talking in detail about the traumatic experience can be difficult and painful. As a result, both parties

may have a vested interest in avoiding a direct processing of the trauma. Trainee/ therapists may avoid encouraging patients to discuss their

trauma for fear that they may cause patients additional pain or harm; therapists may also fear that discussing trauma could heighten their own

feelings of vulnerability. My biggest fear when I began clinical training was that if my client talked about her rape, I might feel overwhelmed and

out of control. During the course of individual and group supervision, I had opportunities to discuss my avoidance. These were helpful

forums to disclose my fears and hear from other trainees about their hesitations and struggles. By the time I started training in longer-term,

non-crisis oriented treatment, I no longer felt afraid of the traumatic material. I had learned techniques that provide a rationale to encourage

clients to talk about their traumatic experiences.
Volume 8 (1) Winter 1998

13

NC-PTSD Clinical Quarterly

POSTDOCTORAL FELLOWSHIPS IN PTSD

Two one-year fellowships available through the multidisciplinary PTSD Training Program at the National Center for

PTSD, Pacific Islands Division of Honolulu Veterans Affairs Medical and Regional Office Center. Training includes

working with veterans in outpatient and inpatient settings, weekly didactics in PTSD, and opportunities to be involved

with PTSD research. Qualifications include: U.S. citizenship, earned doctroate from an APA-aproved program by start

date and completed APA-approved internship. Appointment begins September 1, 1999. The annual stipend is $38,000

(40 hours per week for the full year) and includes ten paid Federal holidays, 13 days annual leave, and 13 days of sick

leave. Complete applications must be received by February 26, 1999. Request application packet from: Education

Coordinator, Department of Veterans Affairs, NC-PTSD, Pacific Islands Division , 1132 Bishop Street, Suite 307

Honolulu, HI 96813. Fax: 808-566-1885.

VA is an Equal Opportunity Employer

3. Training in Empirically-Supported Treatments: Exposure Therapy

Im not sure why I should encourage him to talk about his combat experiences when it seems to get him so upset and makes him more

symptomatic than when we started. -Psychology Intern

Although research on psychological treatments for PTSD is still in the early stages, reviews of the outcome literature support the efficacy

of several psychological treatments (e.g., 6-7). These overviews of treatment efficacy support the use of treatments with a direct exposure

component, such as flooding (8), prolonged exposure (PE; 9), and cognitive processing therapy (CPT; 10). Although I had originally been

trained in a psychodynamic orientation, I found these behavioral techniques offered me both a structured, systematic way to help my patients

process the traumatic material and a clear explanation of the rationale. Instead of inadvertently colluding with a client to avoid traumatic material,

I learned to present the reasons for an exposure-based treatment and to negotiate a clear plan of action. Most importantly, learning exposure

techniques whose efficacy is supported by empirical research and senior trauma clinicians gave me the confidence that, despite the pain, directly

processing the traumatic material was therapeutic.

The topic of empirically-supported treatments also raises the issue of the need for students to be educated about the current state of

research in the trauma field. Although the state of research on trauma and PTSD has made great advances in a short period of time, there are a

minority of researchers who make fantastic claims with little data to back them up. Students need to be critically informed consumers of research

so they are able to identify those reliable findings to guide their clinical treatment and research efforts.

In summary, learning how to manage the unique difficulties when working with traumatized individuals, to avoid collusive hesitation to

directly process the traumatic material, and to employ empirically supported treatment are three important areas to consider during training.

Attending to these issues will hopefully make a more positive training experience for both trainees and supervisors and help to create a new

generation of quality trauma researchers and clinicians.

References

1. Courtois, C.A. (1993). Vicarious traumatization of the therapist. NC-PTSD Clinical Newsletter, 3(2), 8-9.

2. McCann L., & Pearlman, L. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with

victims. Journal of Traumatic Stress, 3, 131-149.

3. Pearlman, L. A., & Saakvitne, K.W. (1995). Countertransference responses to common transference themes with incest survivor clients (pp.

99-119). New York: Norton.

4. Ruzek, J.I. (1993). Professionals coping with vicarious trauma. NC-PTSD Clinical Newsletter, 3(2), 12-13, 17.

5. Young, B.H., Ford, J.D., Ruzek, J.I., Friedman, M.J., & Gusman, F.D. (1998). Disaster mental health services: A guidebook for clinicians and

administrators (pp.134-137). Menlo Park, CA: Department of Veterans Affairs, National Center for PTSD.

6. Solomon, S.D., Gerrity, E.T., & Muff, A.M. (1992). Efficacy of treatments for postraumatic stress disorder: An empirical review. Journal of

the American Medical Association, 268, 633-638.

7. Sherman, J.J. (1998). Effects of psychotherapeutic treatments for PTSD. A meta-analysis of controlled clinical trials. Journal of Traumatic

Stress, 11, 413-435.

8. Keane, T.M., Fairbank, J.A., Caddell, J.M., & Zimmering, R.T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam

combat veterans. Behavioral Therapy, 20, 245-260.

9. Foa, E.B., Rothbaum, B.O., & Steketee, G.S. (1993). Treatment of rape victims. Journal of Interpersonal Violence 8, 256-276.

10. Resick, P. A., & Schnicke, M.K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology,

60, 748-756.
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

14

Clinicians and researchers have

acknowledged that thorough evaluation of

comorbid psychiatric diagnoses is critical to

providing appropriate treatment to individuals

suffering from PTSD (1, 2). It is well

documented that PTSD is associated with high

rates of comorbid mood, substance-related,

and other anxiety disorders (3-6). However,

there have been few systematic attempts to

examine the co-occurrence of psychotic

symptoms in individuals with PTSD.

Consequently, data regarding comorbidity

rates between PTSD and psychotic disorders

or mood disorder with psychotic features are limited.

Epidemiological studies of PTSD conducted by Helzer,

Robbins, and McEvoy (7), Kulka et al. (8), and Kessler et al. (9)

did not assess for psychotic disorders. However, a communitybased epidemiological investigation conducted by Davidson,

Hughes, Blazer, & George (10) reported that 10.9% of

individuals diagnosed with PTSD also met criteria for

schizophrenia or schizophreniform disorder. Additionally, a

review of clinical investigations that evaluated psychotic

symptoms in treatment-seeking PTSD populations revealed

comorbidity rates between 28-35% (11-14), and findings of a

recent investigation by Mueser et al. (15) indicate that there is a

high rate of undiagnosed PTSD in individuals with severe

mental illness. Although there has been a lack of attention to

assessing rates of affective and nonaffective psychotic disorders

in PTSD, preliminary data suggest that there may be a significant

co-occurrence of psychotic symptoms with PTSD.

Our team at the New Orleans VA Medical Center recently

conducted a study investigating the clinical impact of psychotic

symptoms in individuals suffering from PTSD (16). The research

compared functioning of three groups of veterans: one

diagnosed with both PTSD and a comorbid psychotic disorder,

a PTSD group without psychosis, and a group with only a

psychotic disorder. Subjects were assigned DSM-IV diagnoses

(17) on the basis of Structured Clinical Interview for DSM-IV

(SCID) evaluations (18). Results revealed that the PTSD/

psychosis group demonstrated a significantly greater degree

of general psychopathology, positive psychotic symptoms, and

paranoid thinking than the other two groups. While the PTSD/

Psychosis group showed significantly higher levels of psychotic

symptoms and aggression than the PTSD group, the two

groups did not show significant differences in intensity of PTSD

symptoms. These data are consistent with our clinical

observations that PTSD symptoms may exacerbate psychotic

symptoms and paranoid thoughts of some PTSD patients,

and these symptoms can stimulate aggressive feelings and

behaviors. These data also suggest that as many as 35% of

treatment seeking veterans with PTSD may also experience

psychotic symptoms that are distinct from PTSD-related

perceptual disturbances (e.g., flashbacks, trauma-specific

hallucinations, dissociation), and this population represents a

group of trauma survivors with significant vulnerabilities and

unique clinical needs.

Individuals with PTSD and psychotic symptoms

frequently have been deemed inappropriate for traditional

PTSD treatment programs because of a vulnerability to

psychotic decompensation, and PTSD typically is not addressed

within programs geared toward treatment of individuals

suffering from psychotic disorders. Moreover, psychotic PTSD

veterans often relate that they feel they have nothing in common

with veterans diagnosed with psychotic disorders who did not

serve in combat. Staff of clinical programs for treatment of

individuals suffering from psychosis, in addition, may be

reluctant to treat psychotic PTSD veterans because of the

populations propensity toward agitation and aggression.

Hence, opportunities for this group of veterans to receive treatment

for PTSD symptoms have been limited. Our clinical observations

suggest that because of this lack of fit, the distinct needs of

these veterans have gone largely unmet. Given this set of

circumstances, it appears that many of the most severely ill PTSD

veterans have not received adequate treatment for debilitating

PTSD-related symptomatology and, generally, have been grossly

underserved by the prevailing mental health system.

 The PTSD Day Hospital Program at the New Orleans

VA Medical Center was designed specifically to address the

Treatment of PTSD with Psychotic Symptoms

 Madeline Uddo, Ph.D., Frederick J. Sautter, Ph.D., and Larry Pardue, M.D.

 Madeline Uddo, Ph.D. Frederick J. Sautter, Ph.D. Larry Pardue, M.D.
Volume 8 (1) Winter 1998

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NC-PTSD Clinical Quarterly

therapeutic needs of this clinically challenging population

of trauma survivors. Veterans are referred to the program

by local PTSD clinicians. Prior to admission, veterans

undergo comprehensive screening and evaluation to

determine if they are appropriate for the program. A critical

task of the psychological evaluation is to determine whether

the cognitive disturbance experienced by the veteran reflects

the presence of PTSD, a psychotic disorder, or a dissociative

disorder. Veterans complete self report measures that

evaluate PTSD, impulsive aggression, positive and negative

symptoms of psychosis, and general psychopathology. The

SCID is employed to derive DSM-IV diagnoses (17, 18).

SCID interviews are conducted by experienced clinicians

who carefully differentiate among PTSD-related perceptual

disturbances, psychotic symptoms, and dissociative disorders.

Veterans admitted to the Program meet criteria for both

combat-related PTSD and a comorbid psychotic disorder

or mood disorder with psychotic features. Veterans are

excluded from the Program if assessment results reveal that

they meet criteria for a current substance-related disorder,

have a history of medication noncompliance, are unable to

tolerate a group setting, or have experienced an episode of

violence within one month of screening. Veterans are also

excluded if they refuse to sign a behavioral contact that

identifies clinical objectives that the veteran and staff agree

to work toward and specifies conditions for participation

in the program. Specifically, veterans who become members

of the PTSD Day Program agree to refrain from alcohol

and drug use, to take medications as prescribed, and to

control aggressive behavior. Veterans who meet all

requirements are assigned to a case manager and admitted

for a six week probationary period, during which program

compliance is monitored carefully. Veterans who are not

accepted into the program or who do not pass the probation

period are referred elsewhere in the PTSD program for

treatment, e.g., followed individually by a case manager.

The three day a week PTSD Day Hospital Program

began in September 1996. Participation generally ranges

from 15 to 20 male Vietnam veterans. Approximately twothirds of PTSD Day Program members suffer from a

comorbid psychotic affective disorder (major depression

with psychotic features, schizoaffective disorder) while the

remaining one-third meet DSM-IV criteria for either

schizophrenia or psychotic disorder not otherwise specified

(NOS). All of these veterans have experienced chronic

psychotic symptoms since their mid-twenties.

Stabilization is the initial goal of the program. Upon

admission, members undergo medication adjustments as

needed. Although antipsychotic agents are used rarely in

PTSD treatment, Charney et al. (19) suggest that antipsychotic

agents may alleviate certain symptoms. Additionally,

Friedman (20) states that antipsychotic agents may be used in more

severely affected PTSD patients with aggressive symptoms, such

as, overwhelming anger, self-destructive behavior, or severe

frequent flashbacks with hallucinations where other agents may

be less effective. Because members of the program typically meet

the criteria delineated by Friedman, most are maintained on

antipsychotic agents. The usefulness of newer generation novel

antipsychotic agents merits further investigation (21, 22). We are

currently conducting a study to evaluate the efficacy of olanzapine,

one of these novel antipsychotic agents, with PTSD veterans who

experience psychotic symptoms.

The Program consists of a closely supervised social milieu

and an intensive treatment regimen. An integral aspect of the

Program is the therapeutic effect of the milieu. Weekly community

meetings are held, and members are encouraged to manage the

milieu through their own patient government. Because paranoid

thoughts and suspiciousness amplify PTSD symptoms and

stimulate aggression, it is essential to provide a therapeutic

environment so that patients can feel safe and establish supportive

relationships with other patients and staff. Prior to participating

in potentially stressful treatment interventions, it is crucial for

members to experience the milieu as a safe environment. Because

most patients have a history of agitation and violent behavior, it is

necessary to set limits against aggressive behavior in the milieu.

This task is accomplished in as gentle and reassuring a manner as

possible. Explicit rules are provided regarding types of angry

and aggressive behaviors that are not permitted in the milieu, and,

as stated, members agree to a behavioral contract that prohibits

violence. The deleterious effects of violence on the individual

and on the milieu as a whole are discussed. Consequently, the task

of managing anger and agitation in the milieu becomes a

community task in addition to an individual responsibility. For

most of these patients, the milieu represents their first opportunity

in many years to feel that they can experience mutually supportive

social interactions with other human beings.

The intensive treatment program consists of group check

in, psychoeducational group sessions targeting skills training and

relapse prevention, and trauma focus group therapy. The treatment

model was adapted from Carroll and Foy (1). Each session of

the Program begins with a brief group check in where members

report their current level of anxiety, agitation, and general

psychological discomfort. A Subjective Units of Distress Scale

(SUDS) provides a mechanism for members to report this selfassessment. Patients who report an exacerbation of psychotic

symptoms during check in are referred to their case manager who

evaluates the veterans status, determines if he should be permitted

to stay in the milieu that day, and assesses the need for revision of

the veterans treatment plan.

Specific topics are identified for each of the three weekly

sessions. On Mondays, skills training groups are offered which

focus on bolstering positive coping skills (e.g., thought stopping,
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

16

self-talk, seeking support), decreasing negative coping strategies

(e.g., social isolation), teaching problem solving skills, and

reducing social skills deficits. On Fridays, anger and agitation

as well as substance abuse are targeted in a series of groups

that focus on relapse prevention (23). Recreational activities,

or outings, are scheduled for the latter part of the Friday

morning schedule. On Wednesdays, a series of groups focus

specifically upon PTSD symptoms. These groups consist of

graduated therapeutic exposure, cognitive restructuring, and

relapse prevention. Patients must demonstrate that they have

learned to use the coping skills that are taught in the Monday

and Friday groups before they are allowed to participate in the

graduated trauma exposure groups on Wednesday. Patients

are also required to have formulated relapse prevention plans,

and they must demonstrate the ability to implement these

strategies prior to participating in the trauma focus group.

Preliminary research and clinical data

indicate that individuals who meet criteria

for PTSD and experience psychotic

symptoms show significantly higher levels

of cognitive, behavioral, and emotional

disturbance than patients with PTSD

without psychotic symptoms.

As noted in the literature (1, 24), many patients who experience

psychotic symptoms in addition to PTSD are not good

candidates for exposure-based therapy. Patients typically

excluded from our Trauma Focus group suffer from a

nonaffective psychotic disorder and show signs of severe

thought disorder. We have observed that a majority of PTSD

veterans with psychotic symptoms in the Day Program

experience transient or no thought disorder and relatively few

show first rank symptoms of schizophrenia (e.g., delusions of

control, thought insertion). These patients usually meet criteria

for major depression with mood-congruent psychotic features,

schizoaffective disorder, or psychotic disorder NOS. These

veterans typically experience a decrease in psychotic symptoms

as coping skills improve, support increases, and stress and PTSD

symptoms decrease. Many of these members improve to the

point of being able to tolerate and benefit from the Trauma

Focus group. As members move through the treatment

process, they are observed closely and assessed for their ability

to manage stress associated with trauma focus therapy. The

treatment team determines a veterans readiness to participate

in the Trauma Focus group.

The Trauma Focus group provides an opportunity for

members to discuss traumatic events and to participate in

cognitive restructuring of negative beliefs about the trauma.

The group format was modified from existing approaches to

be sensitive to the needs of this population. When psychotic

PTSD patients are entered into the weekly Trauma Focus group,

a rationale for the treatment approach is provided (1). Members

are encouraged to discuss a combat-related traumatic event

that continues to trouble them. It is stressed that they have

control over which trauma scene will be discussed. Veterans

volunteer to speak, and no one is forced to discuss their trauma.

SUDS ratings provide the mechanism by which veterans report

level of anxiety, and the importance of monitoring anxiety

during the session is stressed. It is critical to reintroduce war

trauma gradually so that members do not experience anxiety

of sufficient intensity to exacerbate psychotic symptoms. These

Trauma Focus sessions differ from flooding procedures

frequently used with PTSD patients in that exposure to

traumatic material is gradual, and the goal is to keep anxiety at

a moderate level throughout the session. That is, an important

part of this treatment involves teaching the veteran to re-expose

themselves gradually to war trauma at a pace and intensity that

they can tolerate, while assuring that anxiety level, evaluated via

SUDS ratings, remains manageable. Therapists must be carefully

attuned to the anxiety of each patient so that the exposure

sessions can be orchestrated to minimize risk of symptom

exacerbation.

Trauma Focus work in the PTSD Day Program is

accompanied by a relatively intensive cognitive restructuring

component (1, 25). Often core beliefs and values are altered

by trauma exposure (26), resulting in cognitive distortions

regarding the traumatic event. Cognitive restructuring focuses

on challenging and reframing the distorted trauma-related

beliefs. The procedure requires the patient to identify and list

negative cognitions about their war trauma. These negative

cognitions and beliefs are written on a flip chart and then

discussed and challenged by group members and facilitators.

Members are then asked to formulate more adaptive and valid

cognitions to replace negative ones. This exercise typically must

be done repetitively over long periods of time in order for

negative cognitions to be modified.

The Trauma Focus group is offered in the morning so

that veterans have adequate time for anxiety to extinguish before

the end of the session, and therapists are available for individual

debriefing as needed. Immediately following these groups,

patients are required to attend a Relapse Prevention group which

focuses specifically upon control of PTSD-related symptoms

stimulated by the exposure exercise. Patients are informed

that a critical goal of Relapse Prevention is to learn self-control

techniques so that they can regulate the intensity and duration

of PTSD-related symptomatology. Accordingly, sessions stress

the use of positive coping techniques, such as thought-stopping

and self-talk.

The PTSD Day Program has been well received by

UDDO, SAUTTER, & PARDUE
Volume 8 (1) Winter 1998

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NC-PTSD Clinical Quarterly

patients enrolled. Data from questionnaires administered to

members to evaluate satisfaction with the Program indicate

that most rated the Program as extremely therapeutic, and 70%

of the patients reported that they feel greater control over

PTSD symptoms than when they began the program.

Additionally, these patients appear to experience considerable

relief of PTSD and depressive symptoms in response to

restructuring of relatively concrete aspects of their distorted

trauma-related beliefs. Attendance has been extremely good,

and only three patients have been removed from the Program

because of aggressive behavior. Three members, or

approximately 15%, have experienced adverse reactions to the

Trauma Focus group. This represents a rate slightly lower than

flooding complication rates of 25 - 30% reported by Foy et al.

(27). Empirical studies designed to evaluate the efficacy of the

program and its component parts are in progress.

In summary, preliminary research and clinical data indicate

that individuals who meet criteria for PTSD and experience

psychotic symptoms show significantly higher levels of

cognitive, behavioral, and emotional disturbance than patients

with PTSD without psychotic symptoms. Because these

individuals exhibit severe psychopathology and present multiple

therapeutic and management challenges, treatment resources

traditionally have been limited. This article has described a

nascent treatment program structured to address the special

vulnerabilities of this complicated clinical population. The

treatment intervention incorporates a therapeutic milieu,

psychoeducational groups, and trauma focus group therapy.

Although individuals with PTSD who experience psychotic

symptoms are typically not deemed good candidates for trauma

focus therapy, initial response to this treatment protocol by

psychotic PTSD veterans has been promising.

These preliminary data argue for clinicians to consider

applying a somewhat less conservative decision making bias

when evaluating PTSD patients for trauma focus therapy. Such

an approach would not automatically eliminate patients with

psychotic symptoms, but would instead evaluate risks and

benefits of employing this intervention with psychotic PTSD

patients on a case by case basis. As indicated by Wahlberg (28),

an overly conservative bias denies PTSD patients the

opportunity to participate in an efficacious treatment

intervention (29, 30) that allows them to confront negative

trauma-related cognitions and to articulate the impact of

traumatic experiences. Perhaps the same myths delineated by

Foy (27) regarding the reluctance of trauma therapists to use

exposure with ostensibly more stable PTSD groups applies to

this group as well. That is, Foy suggests that unfounded fears

of decompensation, unnecessary increases in distress, and

depletion of emotional reserves deter trauma therapists from

using exposure-based treatment techniques. An important

caveat regarding conducting trauma focus therapy with

psychotic PTSD patients warrants discussion. It is essential for

therapists to have extensive experienced in working with both

PTSD and psychotic disorders so that early signs of psychotic

decompensation will be detected and appropriate actions can

be implemented quickly to minimize risks to the patient and

the milieu.

In conclusion, surprisingly little effort has been devoted

to understanding the complex interplay between PTSD and

psychotic symptoms. Further research is needed to bolster

clinical efforts and to determine if exposure to extreme stress

is associated with developing psychotic symptoms or if a

predisposition to psychosis increases risk for developing PTSD

following exposure to a traumatic event. Further research will

shed light on disorder overlap and possibly have relevance for

future revisions of PTSD diagnostic criteria.

References

1. Carroll, E. & Foy, D. (1992). Assessment and treatment of

combat-related post-traumatic stress disorder in a medical

center setting. In D. Foy (Ed.), Treating PTSD: CognitiveBehavioral Strategies (pp. 39-68). New York: Guilford

Press.

2. Sutker, P.B., Uddo-Crane, M., & Allain, A.N. (1991). Clinical

and research assessment of posttraumatic stress disorder:

A conceptual overview. Psychological Assessment: A

Journal of Consulting and Clinical Psychology, 3, 520-

530.

3. Kilpatrick, D.G., Saunders, B.E., Veronen, L.J., Best, C.L.,

& Von, J.M. (1987). Criminal victimization: Lifetime

prevalence, reporting to police, and psychological impact.

Crime and Delinquency, 33, 479-489.

4. Mellman, T.A., Randolph, C.A., Brawman-Mintzer, O.,

Flores, L.P., & Milanes, F.J. (1992). Phenomenology

and course of psychiatric disorders associated with

combat-related posttraumatic stress disorder. American

Journal of Psychiatry, 149, 1568-1574.

5. Sierles, F.S., Chen, J.J., McFarland, R.E., & Taylor, M.A.

(1983). Posttraumatic stress disorder and concurrent

psychiatric illness: A preliminary report. American Journal

of Psychiatry, 140, 11771179.

6. Sutker, P.B., Uddo, M., Brailey, K., and Allain, A.N. (1993).

War zone trauma and stressrelated symptoms in

Operation Desert Shield/Storm Returnees. Journal of

Social Issues, 49, 33-49.

7. Helzer, J.E., Robins, L.N., & McEvoy, L. (1987). Post

traumatic stress disorder in the general population:

Findings of the Epidemiologic Catchment Area Survey.

New England Journal of Medicine, 317, 1630-1634.

PTSD WITH PSYCHOTIC SYMPTOMS
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

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8. Kulka, R.A., Schlenger, W.E., Fairbank. J.A., Hough, R.L.,

Jordan, B.K., Marmar, C.R., & Weiss, D.S. (1990).

Trauma and the Vietnam War generation: Report of

findings from the National Vietnam Veterans

Readjustment Study. New York: Brunner/Mazel.

9. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., &

Nelson, C.B. (1995). Posttraumatic stress in the national

comorbidity survey. Archives of General Psychiatry, 52,

1048-1059.

10. Davidson, J.R.T., Hughes, D., Blazer, D., & George, L.K.

(1991). Post-traumatic stress disorder in the community:

An epidemiological study. Psychological Medicine, 21,

713-721.

11. Hamner, M. (1997). Psychotic features and combatassociated PTSD. Depression and Anxiety, 5, 34-38.

12. Hryvniak, M.R., & Rosse, R.B. (1989). Concurrent psychiatric

illness in inpatients with posttraumatic stress disorder.

Military Medicine, 154, 399-401.

13. Jackson, E.I., Tremont, M., Kutcher, G.S., David, D.,

Mellman, T.A. (1996, November). PTSD with psychotic

features. In M. Uddo (Chair), Psychotic symptoms in

PTSD. Symposium conducted at the 12th Annual

Meeting of the International Society for Traumatic Stress

Studies, San Francisco, CA.

14. Wilcox, J., Briones, D., & Suess, L. (1991). Auditory

hallucinations, post traumatic stress disorder, and

ethnicity. Comprehensive Psychiatry, 32, 320-323.

15. Mueser, K.T., Goodman, L.B., Trumetta, S.L., Rosenberg,

S.D., Osher, F.C., Vidaver, R., Auciello, P., & Foy, D.W.

(1998). Trauma and posttraumatic stress disorder in

severe mental illness. Journal of Consulting and Clinical

Psychology, 66, 493-499.

16. Sautter, F.J., Brailey, K., Uddo, M.M., Hamilton, M.F., Beard,

M.G., Borges, A.H. (in press). PTSD and comorbid

psychotic disorders: Comparison of veterans diagnosed

with PTSD or psychotic disorder. Journal of Traumatic

Stress.

17. American Psychiatric Association. (1994). Diagnostic and

statistical manual of mental disorders (4th ed.).

Washington, DC: Author.

18. Spitzer, R.L., Williams, J.B.W., & Gibbon, M. (1994).

Structured Clinical Interview for DSM-IV (SCID-P).

New York: Biometrics Research Department, New York

State Psychiatric Institute.

19. Charney, D.S., Duetch, W.Y., Drystal, J.H., et al: (1993).

Psychobiologic mechanism of posttraumatic stress

disorder. Archives of General Psychiatry, 50, 294-305.

20. Friedman, M.J. (1988). Towards rational pharmacotherapy

for post-traumatic stress disorder. American Journal of

Psychiatry, 145, 281-285.

21. Street, J.S., Tamura, R.N., Sanger, T.M., et al. Long-term

treatment-emergent dyskinetic symptoms in patients

treated with olanzapine and haloperidol. In new research

program and abstracts of the annual meeting of the

American Psychiatric Association; May 8, 1996; New

York. Abstract NR605:235.

22. Davis, J.M., & Janicak, P.G. (1996). Risperidone: A new,

novel (and better?) antipsychotic. Psychiatric Annals, 26,

78-86.

23. Abueg, F.R., & Fairbank, J.A. (1992). Behavioral treatment

of the PTSD-substance abuser: A multidimensional stage

model. In P.A. Saigh (Ed.), Posttraumatic stress disorder:

Behavioral assessment and treatment. Elmsford, NY:

Maxwell Press.

24. Litz, B.T., Blake, D.D., Gerardi, R.G., & Keane, T.M. (1990).

Decision making guidelines for the use of direct

therapeutic exposure in the treatment of posttraumatic

stress disorder. The Behavior Therapist, 13, 91-93

25. Lebowitz, L., & Newman, E. (1996). The role of cognitiveaffective themes in the assessment and treatment of

trauma reactions. Clinical Psychology and Psychotherapy,

3, 196-207.

26. Janoff-Bulman, R. (1992). Shattered Assumptions: Towards

a new psychology of being. New York: Free Press.

27. Foy, D.W., Kagan, B., McDermott, C., Leskin, G., Sipprelle,

R.C., & Paz, G. (1996). Practical parameters in the use

of flooding for treating chronic PTSD. Clinical

Psychology & Psychotherapy, 3, 1-7.

28. Wahlberg, L. (1997). Selecting patients for trauma focus

group therapy. NC-PTSD Clinical Quarterly, 7, 1-4.

29. Boudewyns, P.A., Hyer, L., Woods, M.G., Harrison, W.R.,

& McCranie, E. (1989). PTSD among Vietnam veterans:

An early look at treatment outcome using direct

therapeutic exposure. Journal of Traumatic Stress, 3,

359-368.

30. Keane, T.M., Fairbank, J.A., Caddell, J.M., & Zimering, R.T.

(1989). Implosive (flooding) therapy reduces symptoms

of PTSD in Vietnam combat veterans. Behavior

Therapy, 20, 245-260.

Madeline Uddo is Program Manager of the PTSD Clinical Team at the

New Orleans VA Medical Center and Clinical Assistant Professor in

the Department of Psychiatry and Neurology at Tulane University School

of Medicine. Research interests include assessment and treatment of PTSD

and comorbid disorders.

Frederic Sautter is Associate Professor of Psychiatry in the Tulane

University Department of Psychiatry and Neurology and Staff

Psychologist at the New Orleans VA Medical Center. He is the developer

and Program Manager of the PTSD Day Hospital Program. Research

interests include family and genetic factors associated with the psychotic

disorders and PTSD.

Larry Pardue is Staff Psychiatrist at the New Orleans VA Medical

Center and Clinical Assistant Professor of Psychiatry at Tulane University

School of Medicine.. He is also in private practice and a consultant to

state mental health clinics in Louisiana.

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NC-PTSD Clinical Quarterly

ATTENTION READERS

Due to budget cutbacks, we are no longer able to provide free issues of NC-PTSD

Clinical Quarterly to readers not employed by the VA. You can, however, continue to

receive the Clinical Quarterly at nominal cost by using the Superintendent of Documents

order form below.

This change will ensure we have the funds to continue keeping you informed about

trauma-related topics important in clinical practice, helping to bridge the gap between

scientists and practitioners. We will continue to report on progress in assessing and

treating post-traumatic stress disorder.

We also will continue the Clinical Quarterlys regular columns exploring new directions

in the field and issues specific to womens care.

VA employees will continue to receive the Clinical Quarterly at no cost. If youre not

employed by the VA, make sure you dont miss a single issue of the Clinical Quarterly.

Just complete and return the order form to begin your annual subscription today.
NC-PTSD Clinical Quarterly Volume 8 (1) Winter 1998

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The Education and Clinical Laboratory Education

Division for the National Center for Post Traumatic

Stress Disorder at the Palo Alto CA VAMC, in

collaboration with the VA Employee Education

System offers a Clinical Training Program (CTP).

The training program is approved for 35 Category

1 CEUs for physicians, psychologists, social

workers, and nurses.

Each year we welcome many mental health

professionals from across the United States and

from around the world. Most clinicians who enroll

in the program have a working knowldege about

treating the effects of trauma and PTSD and are

looking to upgrade their clinical skills. The CTP

offers a broad range of educational activities

including:

* Lectures

* Clinical research observation

* Supervised clinical activities

* Use of multimedia material

* Group discussions facilitated by staff

Specific training activities include warzone trauma

group treatment, treatment of women veterans,

treatment of sexual assault related PTSD, relapse

prevention, cross cultural treatment issues,

assessment and treatment of families, disaster

mental health services, cognition and PTSD,

assessment of PTSD, and observation of psychiatric

assessment.

Training programs are scheduled for a minimum

of one week, though longer programs are available

if the applicant can justify an extended stay.

Programs are scheduled nine times per year, generally

on the third week of the month.

At present time, funding for attendance is not

available from the National Center. There is no fee

for the training program itself, but participants are

responsible for providing their own transportation,

lodging, and meals. Interested applicants are encouraged

to explore funding options through their local medical

centers or VA Employee Education System. For more

information, or to request an application, please email:

jir@icon.palo-alto.med.va.gov, or call FTS 700-463-2673,

or commercial number 650-493-5000, ext. 22673.

PTSD Assessment Library

Available upon request are selected instruments from our library of assessment

and program evaluation tools (with accompanying articles), together with

templates describing over 100 trauma-related measures courtesy of

Beth Stamm, Ph.D., and Sidran Press. Telephone (650) 493-5000 ext. 22477.

PTSD Article Library

A helpful set of key articles on aspects of PTSD is available to VA or Vet

Center clinicians free of charge. Telephone (650) 493-5000 ext. 22673.

PTSD Video Library

The Menlo Park Education Team maintains a small videotape lending

library exploring topics related to PTSD diagnosis, evaluation, and

treatment. Videotapes may be borrowed free of charge. Telephone

(650) 493-5000 ext. 22673.

PTSD Program Liaison and Consultation

The Menlo Park Education Team can help VA health care professionals locate

needed resources. Services may include assistance in locating relevant articles,

locating resource persons, or problem-solving. Staff are available to consult in

the areas of PTSD Diagnosis and Treatment, Program Development and

Design, Women and Trauma, Relapse Prevention, and with other PTSDrelated concerns. Telephone (650) 493-5000 ext. 22977.

National Center for PTSD Web Page

The NC-PTSD Home Page provides up-to-the-minute description of activities

of the National Center for PTSD and other trauma related information. The

world wide web address is: http://www.dartmouth.edu//dms//ptsd/

PILOTS Database

PILOTS, the leading electronic index to the worlds literature on PTSD

and other mental health consequences of exposure to traumatic events,

provides clinicians and researchers with the ability to conduct literature

searches on all topics relevant to PTSD. Telephone (802) 296-5132.

NC-PTSD Research Quarterly

The Research Quarterly reviews recent scientific PTSD literature. Telephone

(802) 296-5132 for subscription information.

Disaster Mental Health Training and Consultation

Education staff provide training in disaster mental health services,

including team development, interfacing with other agencies, on-site and

off-site interventions, debriefing, and psychoeducational and treatment

interventions with disaster survivors and workers. Telephone (650) 493-

5000 ext. 22494 or email: bhh@icon.palo-alto.med.va.gov

Conferences and Training Events

The Menlo Park Education Team provides consultative support for the

development of training in PTSD. Services include assistance in finding

faculty and designing program content. Telephone (650) 493-5000 ext. 22673.

 NC-PTSD EDUCATION & SUPPORT SERVICES