CLINICAL QUARTERLY 


PTSD Psychopharmacology Basics 

for Non-physicians and Beginning Psychiatrists 

Linda Nagy, M.D. and Randall Marshall, M.D. 

Veterans with PTSD are often treated with psychiatric medications together with 

psychotherapy. This is particularly true of veterans with severe and complex trauma histories, 

chronic PTSD, or comorbid psychological disorders or poor social functioning. A wide 

variety of medications are prescribed to treat PTSD and common comorbid symptoms, and 

some patients receive multiple medications. This is me despite the fact that there are a limited 

number of controlled trials in PTSD and essentially no trials that examine a combination Dr,hdd,Mmhd Dr.LindaNw 

treatment of medicine and psychotherapy in a controlled study. In other words, the clinical 

need for phannacotheiqy currently is greater than our scientific knowledge of medication treatment. For thisreason, 

an understanding of die expected effects and side effects of these medications can help veterans' primary mental health 

providers facilitate treatment and medication compliance. 

In recent years there has been an increase in pharmacotherapy studies in PTSD and medications (sertialine and 

paroxetine) have for the firs time received U.S. Food and Drug Administration indications for treatment of PTSD. The 

research that forms our knowledge base is more limited compared to that of some other psychiatric conditions, but this 

is an active area of investigation. Still, to date, only two medications have been studied rigorously enough to receive 

FDA approval for use in PTSD. All of the many other medications in use with these patients are used on an "off-label" 

basis because psychiatrists have found them to be helpful in clinical practice. This article sumi~iaiues pha~niacotherapy 

studies of PTSD, and offers some suggestions for facilitating treatment. It is important to note that open trial studies 

and case reports do not provide the more definiive evidence of the effectiveness of medications that can come from 

double-blind, placebo-controlled randomized trials. Results of open trial and case report studies can be subject to error 

from the expectations of both the treating psychiatrist and the patient. Any single trial is unlikely to be representative of 

the entire population of interest, so multiple studies with different populations are ideal. Studies with veterans are 

highlighted in thisarticle since thispopulation may have unique features, particularly in the U.S. 

It is helpful to remember the terms we use to refer to classesof medication, e.g. "antidepressant" or "moodstabilizers" are 

really only shorthand terms, not actual descriptive labels. Most medications have effects on multiple neurotransmitter 

systems and on more than one DSM-IV disorder. In addition, we do not yet fully understand either the neurochemical 

mechanisms involved in PTSD symptoms or die pharmacological effects of most medications. And since receptors are 

located throughout the body, not just in brain, "psychiatric" drugs can have multiple physical effects. Although there are 

factors that suggest a medication is best for a given patient, there is no good way to predict who will respond to which 

medication, so psychopharrnacotherapy, by necessity, involves a trial and en'or process. As discussed by Friedmanand 

colleagues(Z),we now stait withdie selective seiotoninreuptakeinhibitors(SSBIs), as these currently arethe only medications 

for which there is adequate data to support an indication for PTSD, and their tolerability and safety is generally favorable. 
NC-PTSD Clinical Quarterly Volume 11(4)2002 

The regular posting of the National Center for PTSD Clincial Ouarterly on our website (http://ncptsd.org/publications/cq/ 

cqlist.htmD has broadened it's readership to include readers far beyond it's original primary audience, administrators and clinicians 

within the Department of Veterans Affairs and other key government officials. While the CQ has always placed a priority on articles 

related to improving the treatment and quality of life of veterans who suffer from PTSD, it also has made an effort through the years to 

publish informative pieces related to the assessment and treatment of PTSD in other populations (e.g., children, survivors of catastrophic - - ~. 

events, victims of sexual assault, and victims of domestic and community violence). 

We would like to hear from you and extend an open invitation to share your thoughts and ideas about topics and clinical 

issues that you would like to see published in the Clinical Quarterly. 

If you wish to contact us, please do the following: 


email: ncptsd@bruceyoung.net Write CQ Readerin the subject header 


Or alternately, mail your correspondence to: 


Editor, NCPTSD Clinical Quarterly, 795 Willow Rd. (352ell71, Men10 Park, CA 94025 


In addition to your comments and suggestions, please let us know if you have recommendations for additional regular 

appearing columns. Lastly, please include the following information in your correspondence: 

* How long you have been reading the CQ; 

* Primary source for reading: Hardcopy or Website;

* Whether you are a mental health professional or interested non-mental health professional reader; 

And, if a mental health professional: Professional discipline, type of work setting, and population served. 

As in the past, your input will help to keep the Clinical Quarterly relevant and guide it toward its mission to be a valuable source 

for practitioners working to improve the lives of veterans and other individuals suffering from 

'W \ Bruce H. Youn& Editor-in-Chief 

Please fee! free to contact us at [he Education Division: FlS 463-2673/2494; commercial number 650-493-5000 ext, 22673/22494; or E-mail: ncptsd@bruceyoung.net 


Please address all correspondence to: Editor, National Center for PTSD Clinical Quarterly, VA Pal0 Alto Health Care System,795 Willow Rd Q52E117), Medo Park, CA 94025 


34 
NC-PTSD Clinical Quarterly 

Serotonin Reuptake Inhibitors 

Currently, the first-line medication used to treat PTSD 

is usually one of the selective serotonin-reuptake inhibitors 

(SSRIs; 1,2), which are generally known to effectively treat 

depression and anxiety disorders, large scale, double-blind 

placebo-controlled trials have been conducted in PTSD for 

paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac; 

3-5); small open trials are promising for fluvoxa~nine (Luvox; 

6)and more modest for citalopram (Celexa; 7.) The dosages 

used for PTSD are similar to those used for depression and 

An understanding of 

the expected effects and 

side effects of these 

medications can help 

veterans' primary mental 

health providers facilitate 

treatment and medication 

compliance. 

the rime course of response is gradual, such that improvements 

might be apparent after 34 weeks at a therapeutic dose, and 

gradual continued improvement would be expected over a 

period of 8-12 weeks weeks or more. In fact, a recent open 

trial found that patients continued to improve over a 6 month 

period, particularly among patients with high baseline severity. 

8. The degree of improvement is typically partial, for example, 

studies have defined a "responder" as someone who has 30% 

to 50% decrease in PTSD symptoms, e.g. as rated using the 

Clinician-Rated PTSD Scale (CAPS), and a Clinical Global 

Impressions-Improvement rating of 1(very much improved) 

or 2 (much improved). Of patients participating in trials of 

paroxetine, sertraline, and fluoxetine, approximately 50.65% 

of patients receiving active drug met these criteria, and 30- 

40% of patients receiving placebo; for citalopram 31% of 

veterans in an open trial were responders. In general, ratings 

of depression and anxiety improved along with PTSD 

symptoms. Patients treated with paroxetine 20-4Omg'd showed 

sienif~cantimprovement in all three PTSD symptom clusters 

(reexperiencing, avoidance/numbing, hyperarousal), so this 

medication might be expected to treat the full expression 

Volume 11(4) 2002 

PTSD PDYCHOPHARMACOLOGY 

of the disorder. Side effects included weakness, diarrhea, 

abnormal ejaculation, impotence, nausea, andsleepiness. These 

were usually observed at the beginning of treatment and of 

mild to moderate intensity. Sertralie 100-2001ng/d showed 

significant effect for the avoidance/numbing cluster, but 

inconsistent in~proven~ents for the reexperiencing and 

hyperarousal symptoms. Insomnia was more common on 

active sertraline than placebo, affecting 35%; one study also 

reported diarrhea, nausea, fatigue and decreased appetite more 

conmonly than with placebo. Fluoxetine showed significant 

effect for reexperiencing and hyperarousal, and a trend for 

avoidance/numbing symptoms. In the large-scale placebocontrolledtrial for PTSD, "side effects" were equally common 

for active and placebo. This illustrates a point that many 

symptoms such as headache, nausea, insomnia, dry mouth, and 

anxiety may occur in PTSD patients independent of 

medications. There are several promising open trials reported 

for fluvoxamine (Luvox) 100-300mg/d, and in particular, 

robust effects for combat veterans are reported for all 3 

symptom dusters as well as specific improvements in traumarelated dreams and die common problem of interrupted sleep. 

Psychophysiologic reactivity also improved. The side effects 

were primarily in early treatment and included headache, 

insomnia, sedation, and gastrointestinal distress. 

Sexual dysfunction, most commonly delayed ejaculation 

that was not present before treatment, often emerges as a 

concern with SSRIs It can be managed by switching 

medications, "drug holidays" for drugs having a shorter halflife (fluoxetine's long half-life and active metabolite limit this 

option), or taking a second medication to counteract this effect. 

The choices are highly individual and patients should discuss 

the pros and cons with their doctor. The recent paroxetine 

trial found that 20mg had the same effectiveness as 40mg, so 

increasing the dosage conservatively can also help keep adverse 

effects to a minimum (9). 

There is some question of whether civilians and veterans 

respond similarly to medications. For example, a placebocontrolled fluoxetine study conducted in Europe, Israel, and 

Africa reported positive results, and the study included male 

combat veterans. They found that younger patients with more 

recent single events were the most responsive. On the other 

hand, placebo-controlled trials of fluoxetine with U.S. combat 

veterans were negative. Combat veterans in the seitraline trial 

did not respond as well as other subjects, though the sample 

was relatively small. The paroxetine trial included veterans 

recruited from the community, some of whom did respond 

to treatment. This isa question that requi~afurther investigation, 

but one possible explanation has to do with the proportion 

of patients recruited that have already failed multiple treatment 

attempts, and hence are relatively treatment-refractory. 
NC-PTSD Clinical Quarterly 

NAGY & MARSHALL 

Other Antidepressants 

Other antidepressant medications are commonly used for 

symptoms of PTSD and for the frequent conlorbid symptoms 

of major depression or dysthyrnia (10). These include the 

tricyclic antidepressants (TCAs), monoamine oxidase inhibitors 

(~~01s) and newer agents with novel pharmacological 

profiles. 

Tricyclic antideprexs'dl~ts,uch as imiprÂ¥ai~?ine amitriptyline, 

and desipramine have been studied in combat veterans and 

were found to be effective in decreasing reexperiencing and 

avoidant symptoms. A review of TCA studies found 

approximately 45% of patients showed moderate to good 

improvement. They are less frequently used thanSSRIs now, 

due to side effects and partial effectiveness. MAOIs such as 

phenelzine (Nardil) and tranylcypromine (Parnate) have 

demonstrated more robust efficacy than TCAs, with 

approximately 82% of patients showing moderate to good 

improvement, especially for reexperiencing symptoms and 

insomnia, A precaution is the need for a low tyramine diet 

and die avoidance of certain other medications to prevent a 

potentially lethal hypertensive reaction. Patients should receive 

a list of foods and medications to be avoided (such as 

fermented foods, decongestants, opiates) and education prior 

to stating these medications. 

One placebo-controlled trial of nefazodone (Serzone) 

200-600mg/d in veterans reported significant improvement 

for PTSD, especially for hyperaousal(9). Side effects included 

drymouth, &less, gastrointestinal symptoms, and headache, 

and were similar among patients receiving placebo. Six 

additional open trialsof nefazodone supported its effectiveness 

for all tlu-ee symptom clusters, with 30.60% of patients 

responding. Recently, die manufacturer circulated a waning 

about possible liver failure, which, though rare, has increased 

monitoring and caution accordingly. One small uncontrolled 

report examining mirtazapine (Remeron) suggests 

improvement for PTSD in some severe, chronic patients (12). 

In one open trial in veterans, bupropion (wellbutrin) 

ameliorated hyperarousal symptoms (13). Although its 

effectiveness for PTSD is unclear, bupropion is effective for 

smoking cessation inveterans, which canbe an imponant health 

issue. 

Mood Stabilizers 

Several medications such as lithium carbonate and the 

anticonvulsants divalproate (Depakote) and carbainazepine 

(Tegretol) are sometimes used to help stabilize mood and for 

intense initability (1,2). Patients who have con~orbicl bipolar 

disorderwill likely be receiving one of these medications, and 

for those with a history of manic episodes, antidepressant 

medications need to be avoided to prevent triggering a manic 

Volume 11(4) 2002 

PTSD PDYCHOPHARMACOLOGY 

episode or inducing rapid mood cycling. These medications 

require regular laboratory monito~ing for possible side effects 

and checking serum levels. Iamotrigine (Lamid) is a newer 

mood stabilizer with antidepressant properties. One small 

placebo-controlled trial reports PTSD reexperiencing and 

avoidance/numbing was reduced in patients receiving 

lamotrigine up to 500mg/d (14). The main precaution is a 

slow dose increase due to risk of a potentially serious rash. 

Gabapentin (Neurontin) is a newer anticonvulsant examined 

in one chart-review study for PTSD. They report gabapentin 

300-3600rng/d used as an adjunctive treatment improved 

sleep duration and nightrnaic fiqrency inveterans with chronic 

PTSD (15). Side effects included sedation and dizziness. 

Topirainate (Topamax), a novel antiepileptic medication was 

examined in a chart review study of civilian PTSD in dosages 

between 12.5 to 500 mg/d as an add-on or monotherapy 

(16). Patients experienced decreased nightmares, flashbacks, 

and intmsions, and those with PTSD self-ratings had significant 

reductions in all 3 symptom clusters. Another case report 

described a marked positive effect of topiramate in three 

patients who had been unresponsive to previous medications. 

Further study of these agents is needed in PTSD. 

Antipsychotic Medications 

Newer antipsychotic medications, such as olanzapine 

(Seroquel), lispelidone (Risperdal), and quetiapine (Seroquel) 

were initially prescribed for coinorbid psychosis, but there is 

growing interest in use of relatively low doses of these 

medications for severe PTSD symptoms that have not 

responded to other medications or psychotic symptoms. The 

popularity of these newer agents is related to lower likelihood 

of side effect problems that are common with the older, 

traditional antipsychotics, such as tardive dyskinesia, other 

neurornuscularproblen~,and cognitive side effects, and novel 

mechanisms of action. Two open trials of olanzapine 5-20 

mg/d, one in torture victims and one in veterans, found 

excellent response (17). One placebo-controlled study did 

not find active/placebo difference due to a high placebo 

response rate and small sample size. A few case reports 

describe patients who benefited from risperidone. Quetiapine 

25-300 mg/d was studied in 20 combat veterans, a majority 

improved with decreases in all 3 symptom clusters and 

unproved sleep (18). These data for atypical antipsychotics 

are preliminary, but encouraging for further study in PTSD. 

It is important to note that the "typical' antipsychotics 

with primary binding to dopaminergic sites have not been 

shown effective in PTSD. Theoretically, the conscio~~snessimpairment due to side effects from any medication, 

including antipsychotics, might actually impede the capacity 

to process a traumatic event. Thus, the use of atypical 
NC-PTSD Clinical Quarterly 

antipsychotics in PTSD should be considered preliminary 

until controlled data becomes available 

Before prescribing antipsychotics it is also important to 

consider whether apparent psychotic symptoms actually do 

reflect a psychotic process. For example, severe flashbacks can 

be misdiagnosed as hallucinations because consciousness is 

partially impaired during the flashback. In addition, culturallysyntonic experiences that may seem odd or even psychotic in 

die postindustrial West (e.g., seeing the spirit of someone who 

has died, or hearing one's name called aloud), but which are 

not associated with schizophrenic spectrum pathology. (19). 

Other Classes of Medications 

Two uncontrolled reports suggest the anxiolytic buspirone 

(Buspar) was helpful for PTSD (20); this agent nught be used 

in PTSD patients with prominent generalized anxiety disorder. 

The limited studies of benzodiazepines [e.g. alprazolam 

(Xanax),clonazepam (Klonopin)] in PTSD are negative; though 

there was some decrease in anxiety, PTSD symtptoms did not 

improve; and preclinical studies suggest they could hamper 

emotional processing after acute trauma or grief. There are 

additional concerns about dyscontrol and marked exacerbation 

of PTSD symptoms with sudden withdrawal, as well risk of 

abuse/dependence. Another study using a partially controlled 

design found that more patients treated with benzodiazepines 

after a traumatic event had PTSD at 6 months compared to a 

group that was not given benzodiazepines (21). 

..side effects typically appear before 

therapeutic effects, are relatively mild, a 

nuisance only (not dangerous), and often 

subside with continued use of medication. 

Sleep problems are common in PTSD. Trazodone (Desyrel) 

is classified asan antidepressant, but clinically its use is primarily 

for its sedative qualities, especially in combination with SSRIs 

such as sertraline or fluoxetine that worsen sleep. A variety of 

other sleep agents [such aszolpidem (Ambien), chloral hydrate, 

other sedating antidepressants] nught be used in PTSD patients. 

Cyproheptadine (Periactin) was hypothesized to help sleep due 

to actions on serotonin, but was found ineffective and possibly 

worsened sleep in veterans with PTSD (22). It is important to 

realize that making insomnia the primary focus of treatment 

does not appear to reduce PTSD symptoms or play any 

preventative role after acute trauma. A recent placebocontrolled trial found that treatment of insomnia alone with a 

benzodiazepine after a traumatic event did not reduce the risk 

of developing chronic PTSD (23). 

Volume 11(4) 2002 

PTSD PDYCHOPHARMACOLOGY 

Adrenergic agents (beta and alpha blockers) are sometimes 

used for hyperarousal symptoms (1,2). There is some interest 

in use of beta-adrenergic blocking medications, such as 

propranolol (Inderal,) in acute stress disorder to prevent the 

development of PTSD without interfering with essential 

learning and emotional processing during recovery, but this is 

still preliminary. A recent placebo-controlled trial of 

propranolol given to patients in the emergency room after a 

traumatic event had disappointing results (24). There arereports 

of clonidine (alpha-adrenergic agonist; Catapres), propranolol, 

guanfacine (alpha 2A agonist, Tenex), and prazosin (alpha-1 

adrenergic antagonist (Minipres) having beneficial effects in 

individual patients. Larger scale studies and assessment of the 

full range of PTSD symptoms are critical for evaluating the 

use of these agents. 

General Aspects of Pharmacotherapy in PTSD 

The high placebo response rate in many controlled trials in 

PTSD is similar to that seen in depression and anxiety trials, 

and makes large scale studies necessary to detect active/placebo 

differences. Most trials now are req~iig a minimum duration 

of disorder since the natural recovery rate from PTSD is quite 

high in the initial months. 

PTSD patients can be anxious and overly vigilant of physical 

symptoms. Therapists who are aware of this can help patients 

persist with a medication trial if tempted to discontinue 

prematurely. Side effects typically appear early, before 

therapeutic effects, are relatively mild, a nuisance only (not 

dangerous), and often subside with continued use of 

medication. In addition, for the antidepressant class of 

medications, a therapeutic dose needs to be achieved and 

maintained for at least 4 to 8weeks before effectiveness can 

be assessed. 

Patients should be cautioned against making changes they 

have not discussed with their psychiatrist. In addition to 

problems with subtherapeutic or toxic doses, interactions 

between some drugs can lead to an excess of serotonin, called 

a Serotonin Syndrome (e.g., syndrome characterized by 

abdominal pain, diarrhea, sweating, delirium, muscle 

contractions, restlessness, irritability, hostility, and mood change). 

Discontinuations should be planned and gradual, as a 

discontinuation syndrome (i.e., dizziness, nausea, fatigue, flulike 

aches and chills,sensory and sleep disturbances, etc.) can result 

from stopping antidepressants too suddenly. 

Many aspects of pharmacologic treatment have not yet 

been studied. Combinations of medications are often used, 

particularly for severely S. and conlorbid patients. These patients 

are not represented in the medication studies thusfar performed 

in PTSD, so there are no data to clarify use of combinations 

of medication. As with any patient, medication decisions are 

37 
NC-PTSD Clinical Quarterly 

NAGY & MARSHALL 

based on clinical assessment of an individual patient and their 

specific clinical features. In cases when a patient has 

"accumulated" multiple medications over many years it may 

be beneficial to "prune back" and simplify their regimen. The 

goals are to remove ineffective medications, minimize side 

effects and unwanted drug-drug interactions, and improve 

compliance. Therapists can help support the positive nature 

of these changes for patients who express reluctance. 

Thus far there are no dataguiding length of phannacologic 

treatment. One sertraline trial was extended to six months, 

and reported additional improvements. It is not known how 

to determine which patients will relapse after medication is 

discontinued, and which are at risk for relapse. Other chronic 

psychiatric disorders often require long-term treatment and, 

based on clinical experience, it appears that this is true for at 

least some patients with PTSD. Similarly, there is only one 

study to date comparing two medications, and this study was 

conducted before the SSRIs were available (25). None have 

compared medication with psychotherapy, or specifically 

examined the combination. Likewise, it is unclear whether 

medication can be discontinued after an effective course of 

psychotherapy. Tliese are questions [hat require further research 

in PTSD. 

References 

1. 	 Marshall, R.D., Davidson, J.R.T., &Yehuda, R. (1998). 

Pharmacotherapy in the treatment of posttraumatic 

stress disorder and other trauma-related syndromes. 

In RYehuda (Ed.),Psycholoeical Trauma (pp.133177). 

Washington, DC: American Psychiatric Press. 

2. 	 Friedman, MJ., Davidson, J.R.T, Mellman, T.A., & 

Southwick, S.M. (2000). Pharmacotherapy. InE.B. Foa, 

T.M. Keane, & M.J. Friedman (Eds.), Effective 

Treatments for PTSD: Practice Guidelines from the 

International Society for Traumatic Stress Studies. New 

York: Guilford Press. 

3. 	 Tucker, P., Zaninelli, R., Yehuda, R., Ruggerio, L., 

Digham, K., & Pitts, C.D.(2001). Paroxetine in the 

treatment of chronic posttraumatic stress disorder: 

results of a placebo-controlled, flexible-dosage trial. 

Journal of Clinical Psychiatry, 62,860-868. 

4. 	 Davidson, J.R.T., Rothbaum, B.O., vanderKolk, BA., Sikes, 

C.R.,& Farfel, G.M. (2001). Comparison of sertraline 

and placebo in die treatment of posttra~imatic stress 

disorder -ofGeneral 58,485492. 

Volume 11(4)2002 

5. Martenyi, P., Brown, E.B., Zhang, H., Prakash, A., & 

Koke, S.C. (2002). Fluoxetine versus placebo in 

posttraumatic stress disorder. Journal of Clinical 

Psychiatry, 62,199-206. 

6. Neylan, T.C., Metzler, T.J., Schoenfeld, F.B., Weiss D.S., 

Lenoci, M., Gest, S.R., Lipsey, T.L., & Marmar, C.R. 

(2001). Fluvoxamine and sleep disturbances in 

posttraumatic stress disorder. Journal of Traumatic 

-,Stress -, 14 461467. 

7. English, B.A., Ambrose, S.M., Davis, L.L., & Tolbert, L.C. 

Treatment of chronic posttraumatic stress disorder with 

citalopram: An open trial. Poster presentation, 

International Society for Traumatic Stress Studies 17Â¡ 

Annual Meeting, New Orleans, LA, December 7,2001. 

8. 	 Londborg, P.D., Hegel, M.T., Goldstein, S., Goldstein, D., 

Himmelhoch, J.M., Maddock, R., Patterson, W.M., 

Rausch, J., & Farfel, G.M. (2001). Seitraline treatment 

of posttraumatic stress disorder; Results of 24 weeks 

of open-label continuation treatment. Journal of 

Clinical Psychiatry, 62, 325-331. 

9. 	Marshall, R.D., Beebe, K.L., Oldham, M., & Zaninelli,R. 

(2001). Efficacy and safety of paroxetine treatment 

for chronic PTSD: A fixed-dose, placebo-controlled 

study, WN

158,1982-


1988. 


10. Southwick, S.M., Yehuda, R., Giller, E.L, Charney, D.S. 

(1994). Use of ticyclics and monoamine oxidase 

inhibitors in the treatment of PTSD: A quantitative 

review. In M.M. Murburg (Ed.), Catecholamine 

function in cost-traumatic stress disorder: Emerging 

concepts (pp. 293-3051, Washington, DC: American 

11. Davis, L.L., Dafow, M.E., Ambrose, S., Parley, J., English 

B., Bortolucci, A,,&Petty,F. A placebo-controlled 

study of nefazodone for the treatment of chronic 

posttraumatic stress disorder Poster presentation, 

International Society for Traumatic Stress Studies 17th 

Annual Meeting, New Orleans, LA, December 7,2001. 

12. Connor, KM, Davidson, J.R.T., Weisler, R.H., &Ahearn,E. 

(1999). A pilot study of mirtazapine in posttraumatic 

stress disorder. International Clinical Psvchopharmacology, pi,29-31. 
NC-PTSD Clinical Quarterly 	 Volume 11(4)2002 

PTSD PDYCHOPHARMACOLOGY 

Canive J.M., Clark, R.D., Calais, L.A., Qualis, C., & 

Tuason, V.B. (1998). Bupropion treatment in 

veterans with PTSD: An open study. Journal of 

Clinical Ps~chopharmocology, 18,379-383. 

Hertzberg, M.A., Butterfield, M.I., Feldman, M.E., 

Beckham, J.C., Sutherland, S.M., Connor, KM, 

& Davidson, J.R.T. (1999). A prelimiary study of 

lamotrigine for the treatment of posttraumatic 

siress disorder. Biological Psychiatry, 45,126-1229. 

Harnner, M., Brodrick, P., & Labbate, L. (2001). 

Gabapentin in PTSD: A retrospective clinical series 

of adjunctive therapy. Annals of Clinical 

Psychiatry, 13,141-146. 

Berlant, J.L .(2001). Topiramate in posttraumatic stress 

disorder: P- clinical observations. 

of Clinical Psychiatry, 62,Supp117,60-63. 

Stone, R.C., Petty, F, Vinuesa, L., & Un-atte, D. 

Olanzapine treatment for torture survivors with 

severe posttraumatic stress disorder: A case series. 

Poster presentation, International Society for 

Traumatic Stress Studies 17th Annual Meeting, 

New Orleans, LA, December 8,2001. 

Hamner, M.B., Deitsch, S.E., Ulmer, H.G., Brodrick, 

P.S.,&Lorberbaum, J.P. Quetiapine treatment in 

posttraumatic stress disorder: A preliminary open 

trial of add-on therapy. Poster presentation, 

International Society for Traumatic Stress Studies 

17th Annual Meeting, New Orleans, LA, 

December 7,2001. 

Olfson, M., Lewis-Fernandez, R., Weissman, M.M., 

Feder, A,. Gameroff, MJ., Pilowsky, D., &Fuentes, 

M. (2002). Psychotic symptoms in an& general 

medicine practice. American Toumal of Psychiatry, 

B,1412-1419, 

Duffy, J.D. & Malloy, P.F. (1994) Efficacy of 

buspirone in the treatment of posttraumatic stress 

disorder: An open trial. Annals of Clinical 

Psychiatry, 6,3337. 

21. Gelpin, E., Bonne, O., Peri, T., Brandes, D., &Shalev, 

A.Y. Treatment of recent trauma survivors with 

benzodiazepines: A prospective study. 

of Clinical Psychiatry, 52,390-394. 

22. Jacobs-Rebhun, S., Schnuir, P.P., Friedman, MJ., Peck, 

R., Brophy, M., &Fuller, D. (2000). Posttraumatic 

stress disorder and sleep difficulty. American 

Journal of Psychiatry, 1.52,1525-1526. 

23. 	 Mellman, T.A., Byes, P.M., &Augenstein, J.S. (1998). 

Pilot evaluation of hypnotic medication during 

acute traumatic stress response. Journal of 

Traumatic Stress, 11,563-569. 

24. 	 Pitman, R.K., Sanders, K.M., Zusman, P.M., Healy 

A.R., Cheen~a. F., Lasko. N.B., Callill, L., & Orr, 

S.P. (2000). Pilot study of secondary prevention 

of posttraumatic stress disorder with propranolol. 

Biological Psychiatry, 15,189-192. 

25. 	 Kosten, T.R., Frank, J.B., Dan, E., McDougle,C.J., 

& Giller, E.L. (1991). Pharmacotherapy for 

posttraumatic stress disorder using phenelziie or 

imipramaine. Journal of Nervous Mental 

Disorders,m,366-370. 

Linda M. Nagy, M.D. is Assistant Professor of Psychiatryat Dartmouth Medical School, Lebanon, NH 

and Medical Director, PTSD Program at VAMC, 

White River Junction, W.Her work with PTSD 

includes clinical care, teaching, and clinical trials. 

Randall D. Marshall M.D. is Director of Trauma 

Studies and Services, New York State Psychiatric 

Institute, and Associate Director, Anxiety 

Disorders Clinic. Dr. Randall is Associate Professor 

of Clinical Psychiatry, Columbia University College 

of Physicians and Surgeons. 
NC-PTSD Clinical Quarterly Volume 11(4)2002 

Since 1989,this column has given me a unique opportunity to comment on die depth and breadth of new developments 

concerning traumatic stress. I've always insisted that our field encompasses an enormous spectrum of topics from die microscopic 

to the macroscopic. For example, in the last issue of the Clinical Quarterly, I reviewed current brain imaging findings regarding 

neuroanatomic abnormalities associated with PTSD. Thistime I'll focus on traumatic stress from a global socialand humanitarian 

perspective. 

A much awaited book will be published this spring, Trauma Interventions in War and Peace: Prevention. Practice and 

&!icy, published by Kluwer Academic/Plenum Publishers, It is die c~~lminationf a five-year collaboration between the 

United Nations and the International Society for Traumatic Stress Studies (ISTSS). The book was initiated by a request to 

ISTSS from John Langmore during his tenure as Director of the UN'S Division for Social Policy and Development within its 

Economic and Social Council (ECOSOC). He was later joined in tills request by Martin Barber, Director of the UN'S Office 

for the Coordination of Humanitarian Affairs (OCHA). Both men were concerned that the importance of trauma-related 

issues had neither been adequately acknowledged nor incorporated into die UN'S various nllssions. The book is but one 

component of an ongoing procedural initiative to influence UN policy and practice by detailing the impact of traumatic stress 

on the millions of people world-wide requesting or receiving UN assistance. 

In order to produce both the book and associated UN documents, ISTSS's UN representative, Ellen Frey-Wouters, 

invited Terry Keane and, later, myself (as current and past presidents, respectively) to meet with John Langmore and Martin 

Barber and their colleagues from ECOSOC and OCHA. With their enthusiastic encouragement and support, the project 

quickly expanded to include approximately 50 international experts drawn from countries from the less and more developed 

regions as well as from countries in social and economic transition, with representatives from Argentina, Australia, Bangladesh, 

Barbados, Brazil, Canada, Denmark, Egypt, Ethiopia, Gemmy, India, Israel, Japan, Kenya, die Netherlands, Norway, Russia, 

Samoa, Slovenia, South Africa,SriLanka,Turkey, Uganda, the United Kingdom, and die United States of America. Production 

of the book was a daunting and complicated endeavor. Bonnie Green served as senior editor with assistance from myself, 

Joop de Jong, Susan Solomon, Terry Keane, John Fairbank, Brigid Donelan, and Ellen Fr-ey-Wouters, as co-editors. Yael 

Danieli served as Special Editorial Consultant and Stacy Kaltnm worked closely with Bonnie as special assistant. 

To a person such as myself, trained as a clinician in a traditional one-on-one clinician-patient context, there were many new 

lessons to be learned in the course of this UNASTSS collaboration. (These lessons later helped me to think about massive 

trauma in nontraditional ways after die September 11"'terrorist attacks which affected millions of Americans directly and 

indirectly.) First it was necessary for us to understand die consequences of traumatic stress from a public health perspective as 

a widespread problem that must be addressed from a societal/comrnunity rather than from a traditional individual clinical 

perspective. Second, the majority of people most affected by traumatic stress tend to come from resource-poor regions, 

nations and communities, lacking safety, security, sanitation, nutrition, health care, education, and the tools needed to live 

productively and independently. In addition, they usually lack more than a very small fraction of the well educated and 

adequately equipped professionals needed to provide basic services,In other words, following massive casualties or traumatization, 

traditional one-on-one clinical approaches just won't work because of the magnitude of need and the miniscule amount of 

available resources and qualified assistance. 
NC-PTSD Clinical Quarterly Volume 11(4) 2002 

NEW DIRECTIONS 

As a result, a different model for global social and humanitarian intervention is essential. In our book, we offer the inverted 

psychosocial pyramid as die only viable conceptual ancl practical approach. The basic premise of the inverted psychosocial 

pyramid is that primary interventions must be designed to assist society as a whole. We propose four different levels of 

program intervention. Interventions designed for the whole population are the most cost-effective approaches. As we descend 

die pyramid, interventions target progressively smaller groups of people, until die pyramid's apex where the most costly, 

traditional one-on-one clinical interventions can be found that require clinical staff with specialized training. There are different 

types of interventions at each level witha successive focus on safety, legislative and public policy, public education, coordination, 

capacity building, training/eclucation, self-help, counseling or clinical treatment. 

In brief, Societal Levels of Intervention include internationaUnationa1 laws and public policy that promote safety, security, 

health, mental health, human rights, social justice, as well as availability and coordination of essential services. Societal interventions 

are both preventive and reactive measures designed to meet the psychosocial needs of those exposed to massive traumatic events 

in die most effective manner 

Community/Neighborliood Interventions may include public education, community empowerment, capacity building ancl 

training in addition to provision and coordination of direct assistance (through die UN or Nongovermnental Organizations). 

Family Interventions make use of informal support systems of family, friends, neighbors and peers. As with community/ 

neighborhood interventions, this level of support relies as much as possible on existing formal or informal networks arid is often 

implemented by utilizing die indigenous leadership structure of such networks. 

Finally, Individual Interventions are much more like traditional therapeutic and pharmacological clinical approaches when 

qualified personnel and available. They are the most costly and assist the smallest number of people, but for well-selected cases 

who have failed to benefit from larger-scale approaches, they are the interventions that are required. 

As for the chapters themselves, they are divided into three major sections: general, social, and humanitarian. General issues 

include trauma-related factors pertinent to prevention, practice and policy regarding all the specific topics covered in subsequent 

sections of the book. Chapters on general issues address: the prevalence of trauma world-wide, die impact of traumatic-stress 

on individuals and society, social deprivation, and intervention options (based on die hierarchy ofappioaAes within the framework 

of the inverted psychosodal pyramid) for society, communities, families and individuals. Chapters on social issues focus on: child 

abuse in peacetime, abuse of the elderly, people with mental and physical disabilities, victiim of crime (including issues pertinent 

to human rights and social justice), and survivors of mass violence and torture. Finally, humanitarian-focused chapters address: 

children in armedconflict,refugees andinternally displaced people, fonner combatants, and survivors of natural and technological 

disasters. The last chapter in the humanitarian section may interest many readers of the Clinical Quarterly since it focuses on the 

impact of traumatic stress on UN peacekeepers and civilian field personnel, Finally, the book ends on what we term a "call to 

action" regarding necessary and appropriate responses to social and humanitarian crises. 

Since I believe that the field of traumatic stress is inherently global ancl humanitarian, this book is a long overdue status report 

011 current practice and policy. We're at a very early stage in ~mlating scientific and clinical knowledge about traumatic stress into 

social and h~imanitarian action. Our book is a useful contribution, in that regard, but it is only a start. Hopefully, it will help guide 

future policy and practice in this most important arena of human endeavor. 
NC-PTSD Clinical Quarterly Volume 11(4)2002 

Group-administered early intervention 

Groups are important for early intervention. When individual care may be difficult to deliver 

(e.g., due to large numbers of affected persons, lack of availability of mental health providers, or costconstraints), they provide a potentially cost-effective way of serving survivors. In some cases, trauma 

survivors are part of an existing group structure (e.g., work colleagues, military units), and that group 

will continue functioning as a unit and act as part of the ongoing recovery environment. In addition, it 

is possible that some helping processes may be better activated in groups than in one-to-one care. While 

little is known about the effectiveness of early group services in preventing PTSD and other traumarelated problems, evidence suggests that group treatment is beneficial for those with chronic PTSD (1). 

There would seem to be much to recommend groups as delivery environments for early 

intervention services. Trauma survivor support groups are typically comprised of those who have 

undergone similar traumatic experiences and are thus well-suited to challenge common distressing 

perceptions of survivors (feeling alone, different, misunderstood by those around them) and reduce 

social isolation. Groups may be especially useful in helping survivors address the worries associated 

with traumas that are particularly difficult to talk about with family and friends, due to perceived social 

stigma, embarrassment or shame, guilt, or fear of negative reactions from others (e.g., sexual assault). 

Probably one of the most potentially powerful components of group interventions is social support. 

Greater received and perceived social support and higher levels of social embeddedness have been 

associated with less distress among disaster survivors (2), and lack of social support post-trauma is a 

risk factor for PTSD (3). Social support is actually an umbrella term that describes practical help with 

problems, emotional understanding and acceptance, normalization of reactions and experiences, mutual 

instruction about coping, and informal cognitive therapy. A special case of group-related social support 

is the self-help or mutual aid group. When survivors join together to help one another, they do much to 

reestablish a sense of control over events. Often, they go beyond mutual emotional support to address 

political or legislative issues affecting themselves and their community. 

Groups may be used soon after traumatization to provide education, mobilize social support, and 

train skills for coping with traumatic stress reactions and other post-trauma challenges. Education, a 

component of all efforts to provide early mental health response, may be usefully delivered in a groups. 

Intended to improve recognition and understanding of reactions, reduce fear and shame, and, generally, 

'normalize" the experience of the survivor, education can make symptoms seem more predictable and 

less frightening and help individuals cope more effectively. Education should also aim to reduce negative 

forms of coping with symptoms, such as alcohol or drug use, social withdrawal, and extreme emotional 

avoidance. Finally, education should give participants information to help them better decide whether 

to seek further treatment. It should include matter-of-fact descriptions of what happens in counseling 

and group discussion about obstacles to help-seeking (e.g., stigma). 
NC-PTSD Clinical Quarterly Volume 11(4)2002 

EARLY INTERVENTION 

The primary current model of early group intervention to reduce the impact of trauma is group stress 

debriefing (4).The idea is to pull together groups of persons affected by a common event, mobilize their 

support for one another, provide education to help normalize stress reactions, give advice about coping, facilitate 

the working through of the event, and give information about available services. The debriefing encounter 

also provides a significant opportunity for identification and referral of those requiring more intensive counseling. 

It is characterized by a sensitive effort to approach the experience in a gradual manner, starting with factual 

information moving toward discussion of feelings associated with the trauma, and exiting from the procedure 

via information about coping. While there is much debate about the advisability of early exploration of the 

traumatic experience, the goals of normalizing reactions, improving coping, mobilizing support, and directing 

to available services are generally well accepted by trauma specialists. However, a primary limitation of 

debriefing is a limitation of "psychoeducation," that is, a combination of simple advice and group discussion 

is likely to be limited in its impact on the more complex actions important to recovery. When presentation of 

information is expanded to include opportunity to observe and practice coping behaviors, likelihood of behavior 

change may increase. Some of the change "technologies" used in group treatment for other problems should 

be harnessed in the context of early post-trauma group intervention: demonstration of skills; skills training 

with instruction, practice, and coaching; self-monitoring or diary-keeping of key behaviors; and use of task 

assignments. 'Wherever possible, groups should involve multi-session contact, so that key messages can be 

repeated, supportive relationships among members can be developed, skills can be polished, recovery behaviors 

can be shaped and reinforced, and group helping processes can be extended in duration. Groups are important 

in post-trauma care, but there is a need for rethinking of their application; new models of structured early 

interventions with groups are needed and research on the preventive impact of evolving models is a priority for 

the field. 

References 

1. Foy, D.W., Glynn, S.M., Schnurr, P.P. Jankowski, M.K., Wattenberg, M.S., Weiss, D.S., Marmar, C.R., & Gusman, 

F.D. (2000). Group therapy. In E. B. Foa, T. M, Keane, & M. J. Eriedman (Eds.), Effective Treatments for PTSD: 

Practice Guidelines from the International Society for Traumatic Stress Studies (pp. 155-1751, New York: Guilford 

Press. 

2. Noms, F.H., Friedinan, M.J., Watson, P. J.,Byrne, C.M., Diaz, E., & Kaniasty, K. (2002). 60,000 disaster victims 

speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry, 65,207-239. 

3. Brewin, C.R., Andrews, B.,&Valentine, J.D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder 

in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68,748-766. 

4. Raphael, B. &Wilson,J. P. (2000). Psychological Debriefma: Theory, Practice and Evidence. Cambridge, UK: 

Cambridge University. 

CORRECTION 

The last issue of the Clinical Quarterly errored in the listing of authors contributing to Women and Trauma: A 

Clinical Forum, leaving out Amy Nagle, Ph.D. The correct author listing for the article entitled " The role of 

. self-defense training in preventing sexual revictimization" is Annabel Prins, Ph.D., Amy Naugle, Ph.D., Claire 

Sandringham, MS., and Julie Weitlauf, Ph.D. 
NC-PTSD Clinical Quarterly Volume 11(4) 2002 

HOMICIDE: HELPING CHILDREN IN THE AFTERMATH 


ALISON SALLOUM, L.C.S.W 

Every year in the United States thousands of children An ecological and holistic 

and their families cope with die aftermath of homicide. Such a approach that simultaneously maintains 

violent death and the consequences of unresponsive and/or focus on the child and their 

unsupportivesystemsmaycauseseverepsychologicalandsocial environment in a reciprocal 

ddenges among these survivors. Group treatment approaches 

for adolescent survivors have shown promising results (1-21, 

but studies regarding individual and family treatment for children 

remain scarce, although theoretical and practice approaches 

have been described (3-6).Wl-~ilethe bereavement literature 

offers a foundation for working with children, factors due to 

the homicide must be considered. Key issues to consider when 

working with children after homicide include die context, die 

factssur~o~~nding die death, family strengths and socialsupports, 

the family's grief prncexs, 1 

relationship over time provides a 

framework for worldng with children 

and their families after homicide. Such 

an approach includes all systems and 

environmental factors that impact die AI~SO,, saiioun,LCSW 

child and their family in the aftermath of homicide in addition 

to those included in the tripartite assessment. 

The media may add stress for die family by sensationalizing 

the crime, being the first to notify die family members by way 

1 of broadcasting the crime (81,asking intrusive or 

grief and trauma 

reactions, and issues of 

revenge. These key 

issues will be explored 

using research and 

literature legaidingchild 

smvivois/ witnesses of 

homicide, beieavement, 

andtrauma,aswellasthe 

author's practice experiAn assessment of grief and inappropriate questions, or not providing much 

coverage at all. However, the media can have 

tra~ticreactionsshould positive effects on the family by providing 

be Conducted affected information to solve he case, providing an avenue 

for the family to share their pain with the family members, in~l~~~~g community, and emphasizing and giving meaning 

VCT~ chiBen U)ho aye to their loved one's life @). 

often overlooked. 


encewith low-income fandies"who have had lovedones murdered. 

CONTEXT: SYSTEMSAND ENVIRONMENTALFACTORS 

Webb's (7) interactive tripartite assessment, which includes 

individual factors, death-related factors, and factors in the 

support system, provides a basic foundation for assessing 

bereaved children. Individual factors inclnde variables such as 

age, developmental stage, cognitive stage, temperamental 

characteristics, past coping, past experience with deathtloss, 

peers, interests, and medical history. Death-related factors 

include degree of pain, presence of violence/~auma, element of 

stigma,presenceat death, anendance at ceremonies, relationship 

to deceased, meaning of loss and grief reactions. The third 

main category of factors is the support system dial can 

sigrufrcandy contribute to resilience and/or risk factors in coping 

with the death. Factors in the support system include nuclear 

family, extended family, school, peers, religious affiliation, and 

cultural affiliation. However, if children are bereaved due lo a 

homicide that affectsallfamily members, praciitioneis must extend 

thistripartite assessment to consider numerous other factors. 

The absence of a perpetrator or the slow 

response of the court system causes additional 

stress on the family (10). Survivors' criticism of 

police and the criminal justice system may be warranted in 

some cases, but such criticism niay also be due to 

misinformation about the process and the desire for swift 

justice. Low-income and minority survivors have reported 

that they felt die police, detectives and entire crinlinal justice 

system did not respond to their needs because of their class 

and race (11-12). Spungen (9, p.179) advocates that when 

working with survivors we "should act as watchdogs for biased 

acts perpetrated against co-victims [a term for survivors] and 

actively seek to modify due system in a positive way." Survivors 

niay need to be provided with education about the criminal 

justice process. Child survivors need special attention and need 

to have their questions answered according to their capacity to 

understand. If practitioners are not able to provide information 

or to advocate for the suivivois, avictim advocate may need to 

become involved, especially if any family member is a witness. 

Other environmental factors that may impact the family 

need to be considered such as the responses of die school and 

peers, housing issues, employment leave time, and finances. 

For example, for families without economic resources, pressing 
NC-PTSD Clinical Quarterly 

issues of finances and housing that have resulted from the 

homicide may take precedence over participating in 

psychotherapy(12). Parents (or caregivers) should be infoniied 

about crime victims' reparations programs. Case management 

and advocacv niav need to be offered in addition to 

psychotherapy, especially for low income and/or minority 

groups who may have additional challenges after die homicide. 

Further, community-based services that are offered at flexible 

times and locations (community centers, schools, home, 

churches, workplace) should be considered especially for lowincome survivors because of barriers such as transportation, 

daycare, safety, stress, and limited leave time from work. 

The "Facts" 

Homicide is a public concern and many people may have 

infonilation about the crime. Reports and accounts from die 

media, detectives, witnesses and neighbors may all lead to 

distorted information about what happened. Further, the 

surviving adult members may have their own story and beliefs. 

As a result of various accounts of the mvirder, children often 

have a confused understanding about what happened (13). 

Practitioners should ask parents (or the primary caregiver) about 

their understanding of what die child knows. Many times, we 

may begin by asking eadi family member how he or she found 

out about what happened. Adults are often surprised to leam 

that the child lias heard different stories from various sources. 

Practitioners may need to assist the parents in explaining in a 

developrnentdy appropriate manner die necessaiy details about 

what happened (13). Furtherniore, both practitioners and 

parents(and caregiveis) must provide and convey a senseof safety. 

This is often a difficult challenge if the perpetrator has not 

been apprehended. However, helping the child to regain a sense 

of safety is one of the most important goals. Consistent 

environments that promote a sense of safely need to be created. It 

is important that surviving children be around people who 

care about and nurture them. Also, routines need to be 

establishedor reestablished (14). If the primary caregiverlias died, 

the child needs to know as soon aspossible who will take care of 

them, as this isoften a worry espedy of young children. 

Strengths and Social Supports 

Practitioners must work collaboratively with survivors of 

homicide victims in a manner that conveys hope and highlights 

the strengths of die child and their family. An assessment of 

the child and family's strengths, social supports and 

environmental resources should be conducted. When their 

positive capacities are supported, children and their families 

are more likely to act on their strengths (151,wluch can help 

Volume 11(4)2002 

HOMICIDE: HELPING CHILDREN IN THE AFTERMATH 

facilitate survivors in coping with the many systems involved 

and proniote restoration. Rynearson (161, who developed a 

restorative retelling approach primarily used with adult 

survivors, states that promoting resilience must be the first 

priority. He proposes that a series of open-ended questions, 

which inquire about current available supports, past coping 

strategies, current needs, and memories of die deceased, be 

used to explore and proniote the capacity and resources of 

survivors.In addition to these questions, practitioners need to 

help children identify other family members or friends they 

cantalk with or from whom they feel comforted. Also, because 

children spend so much time at school, teachers, school 

counselors and other school officials may need to be informed 

about ways to support them. In addition, children's positive 

abilities, talents, and interests must be supported as these strengths 

can help establish a sense of master)' and control, which is 

often unstable after a violent death. 

The Family's Grief Process 

Grieving parents and caregivers may have a difficult 

time responding to the ernotional needs of their children due 

to their own grief and/or trauma (17) and they may need 

individual or group therapy to focus on their needs. However, 

even when parents and caregivers are available to assist their 

child in coping with die death, some children may be hesitant 

to share with their parents because they do not want to add to 

their pain or place additional stress on them (11).All family 

members need to be educated about the uniqueness of 

members' grief and encouraged to respect each person's 

approach to coping, as well as to be patient with one another. 

Not only are the family members' relationships to the deceased 

different, but their response to the violent death may also vary 

(18). Family members need to be educated about 

developniental traumatic and grief responses. Further, we must 

work wilh fanilies in die context of understanding their cultural 

beliefs and practices, which may influence the variations in 

family members' traumatic and grief responses (19). Also, it is 

important to be aware of the family members' religious and/ 

or spiritual beliefs and practices, which often become salient 

after a death and can help or hinder die healing process (20). 

Generally, proximity to die violence and/or violent dying 

and degree of life threat increases traumatic symptomotology. 

Further, the closer the relationship between the survivor and 

the deceased, the greater die grief experienced. However, other 

factors such asthe media showing graphic images and feelings 

of guilt may impact the severity of trauma and grief (21). An 

assessment regarding grief and traumatic reactions should be 

conducted with all affected family members, including very 
NC-PTSD Clinical Quarterly 

SALLOUM 

young children who are often overlooked (22,231. Further, 

practitioners need to assess for children's prior traumatic 

experiences and losses, which can cause severe disturbances 

(24). Also, prior and current mental illness, prior trauma and 

loss and substance abuse within the entire family needs to be 

assessed and. if needed addressed. 

Children's Grief and Trauma Reactions 

Silverman and Worden (25) exanined die reactions of a 

nonchical group of 125 children aged six to seventeen years 

(70 families) who were within four months of a death of a 

parent. Grief reactions included crying, insomnia, difficulty 

concentrating, headaches and other somatic complaints, and 

for most children these symptoms were not prolonged and 

the stress did not seem to overwhelm the children. However, 

88%of deaths were from natural causes and only one death 

was as a result of homicide. Research with child, adolescent 

and adult survivors of homicide victims has revealed significant 

levels of traumatic stress (21,26-29). Traumatic stress after 

death includes intrusive thoughts, reexperiencing traumatic 

aspects,avoidance, fear, and hyperarousal, which are related to 

the thoughts and images of die dying and the events surrounding 

the death (30). Children and adolescents experience traumatic 

grief when both traumatic stress and bereavement occur, and 

when the posttraumatic stress reactions impinge on the child's 

ability to progress with the bereavement process (31). 

Not all child survivors will experience traumatic symptoms. 

Therefore, both grief and traumatic responses and the 

combination of the two need to be assessed. Multiple sources 

and techniques for gathering information should be used (32). 

Assessment scales that have been used with children after 

violent death may be useful. The revised child posttraumatic 

stress reaction index is frequently used with children ages 6-17 

who have had someone close die due to homicide (21). 

Alternative criteria and approaches for diagnosing (331, assessing 

and treating posttraumatic stress with very young children have 

been developed and should be used with young children since 

theyarenot able to describe veibally internal states (34).Current 

assessment scales regarding childhood bereavement and 

traumatic grief may be obtained from the National Center for 

Child Traumatic Stress (phone: 310-235-2633). 

Practitioners need to have an understanding of how grief 

and trauma are expressed developmentally and interventions 

must be tailored accordingly. For example, Nader (4) slates 

that when using trauma and grief-focused therapy with preschool children the emphasis is on play with the practitioner 

verbalizing the reactions and sequences. Play, drawing and 

cognitive approaches are used with school-aged children; 

more emphasis on discussion, including role-play and demonstration, is used with adolescents. Eth and Pynoos (35) 

Volume 11(4)2002 

explain different developmental responses of preschool (3 

through 51, school age (6 through 12) and adolescents (13 

through 18) who have witnessed the homicide of a parent. 

However, similar reactions may occur with child survivors who 

did not directly witness the violent dying as they may have 

heard about it or witnessed the aftermath. Therefore, 

practitioners should assess for traumatic reactions such as the 

following: Preschool children, who are often passive observers 

of the violence, commonly feel defenseless, experience sleep 

disturbances, avoid reminders, engage in reenactment play, 

experience intensified separation anxiety, and may display 

regressive behaviors from previously attained skits. School age 

children may experience inability to concentrate (often resulting 

in declining school performance), intrusive memories about 

the death, fantasies of intervening and rescuing the person, 

obsessive recounts of details, avoid reminders, hypervigilance, 

irritability, decreased self-esteem and self confidence, 

reenactment play, and have psychosomatic complaints such as 

headaches and stomachaches. Adolescents may engage in 

posttraumatic acting-out behavior such as school truancy, 

precocioussexualactivity,substanceabuse and delinquency. Such 

behaviors along with poor impulse control and rebelliousness 

puts these youth at a high risk for hurting themselves and others. 

Ohexresponsesincludegdt,scrutiny about how they responded 

during the murder, and concern about their future (35). 

Interventions should be geared toward decreasing traumatic 

reactions and facilitating grief while promoting coping strategies 

and support. Reducing the traumatic reactions may take 

precedence over facilitating the grief work as thoughts of the 

deceased might lead to traumatic reminders (4,361. Nader 

(17) explains that with childhood traumatic loss, the interplay 

of grief and trauma affect the bereavement process and 

symptoms common to both become intensified. For example, 

while anger is a common grief response, if trauma is present, 

it may be rage. Grieving children may think that somehow 

they caused the death and feel guilty; with trauma, guilt may 

be intensified because the child feels not only responsible, but 

helpless for not having been able to save the victim. Also, 

traumatic aspects may interfere with memories and dreams 

about the deceased, complicating the bereavement process. 

Further, with trauma, children may detach from others and 

feel more alone, which may interfere with others being able to 

help them grieve and cope. Children may have gruesome 

mental images of the violent death (whether they witnessed it 

or not) leaving them with a disturbing image of the deceased. 

It is important that practitioners work with children to restore 

memories of the deceased prior to the death. Such restored 

memories and positive feelings of connection to the deceased 

canhelp children cope with the loss (131, especially when other 

family members support thisprocess. 
- - - 

NC-PTSD Clinical Quarterly 

Revenge Assessment 

Children may have thoughts and fantasies of revenge. 

Younger children may also express fears that die perpetrator 

will return and kill them too (12). Such thoughts of revenge 

and intervention fantasies can be explored in the context of a 

safe therapeutic environment. In addition, we must take die 

possibility of retaliation seriously and assess for gun accessibility 

and revenge plans (see 37 for homicidal risk assessment). Tile 

issue of revenge may need to be raised within the entire family. 

Family members may share that they too have had revenge 

thoughts, which provide normalization of such thoughts and 

wishes. However, and more importantly, older family members 

are encouraged to give clear messages that they do not want 

their children (including adolescents) to follow through with 

such revenge plans. 

Conclusion 

The assessment and treatment considerations explored in 

this article certainly do not address all of the issues that may 

arise, as there are many unique factors associated with every 

child and their family who had a loved one die due to violence. 

However, research and practice experience does identify key 

issues to consider. As the fields of trauma and bereavement 

evolve, practitioners must keep abreast of promising and 

effective approaches to help children and their families in the 

aftermath of violent death. However, this must not be our 

sole focus; we must promote policies, funding, research and 

activities that prevent such tragedies from occurring in the first 

place and that create safer environments for our children. 

References 

1.Layne, C.M., Pynoos, R.S. & Cardenas,J. (2001). Wounded 

adolescence: school-based psychotherapy for adolescents 

who sustained or witnessed violent injury. In M. Shafii 

& S. Shafii, (Eds.), School violence: Assessment, 

management, prevention (pp. 163-1861, Washington: 

American Psychiatric Press. 

2. Salloum, A,, Avery, L., & McClain, R.P. (2001). Group 

psychotherapy for adolescent survivors of homicide 

victims:A pilot study. Journal of the American Academy 

of Child and Adolescent Psychiatry, 40,1261-1267. 

3.Levy, AJ. &Wall, J.C. (2000). Children who have witnessed 

community homicide: Incorporating risk and resilience 

in clinical work. Families in Society, 81,402. 

4. Nader, I<. (2002). Treating children after violence in schools 

and communities. In N.B. Webb (Ed.), Helping bereaved 

children: A handbook for practitioners (Znd ed., pp. 19- 

42). New York, NY: The Guilford Press. 

Volume 11(4)2002 

HOMICIDE: HELPING CHILDREN IN THE AFTERMATH 

5.Parson, E.R. (1997). Post traumatic child therapy: Assessment 

and treatment factors in clinical work with inner-city 

children exposed to catastrophic community violence, 

Journal of Interoersonal Violence, 12,172-194, 

6. Temple, S. (1997). Treating inner-city families of homicide 

victims: A ~0nte~hldly 01-iented approach 

Process, 36,133-149. 

7.Webb, N.B. (2002). Assessment of the bereaved child. In 

N.B. Webb (Ed.), Helping bereaved children: A 

handbook for practitioners (Znd ed., (pp. 19-42). New 

York, NY: 'Hie Guilford Press. 

8. Sprang, V.M., McNeil & Wright,R. (1989). Psychological 

changes after the murder of a sig&rcant other.&&l 

Casework, 2,159-164. 

9. Spungen, D. (1998). Homicide: The hidden victims: A guide -

for professionals. Thousand Oaks, CA: Sage 

Publications. 

10.Bard, M., Amone, H.C., & Nemiroff, D. (1986). Contextual 

influences on the post-traumatic stress adaptation of 

homicide survivor-vich. In C.R. Figley (Ed.), 

and its wake. Volume U: Traumatic stress theory. research 

and intervention (pp. 292-304). New York, NY: 

Bmnner/Mazel, Inc 

11.Freeman, L.N.,Shaffer, D., Smith, H. (1996). Neglected 

victims of homicide: The needs of young siblings of 

murder victims. American Tournal of Oithoosvchiatry, 

66,337-345. 

12.Udell, M.E. (1995). Surviving sibling murder: An analysis 

of eight mental health interventions for inner-city youth. 

Dissemtion Absuxcts International, %, (6-B), 3467. 

13. Clark, D.C., Pynoos, R.S. & Goebel, A.E. (1996). 

Mechanisms and processes of adolescent bereavement. 

In R. Hoggerty, L. Sherrad, N. Garmezy, N. & M. 

Rutterf Eds.), Stress. risk and resilience: children and 

adolescents (pp. 100-146). New York, NY: Cambridge 

University Press. 

14. Lovrin, M. (1999). Parental murder and Suicide: Posttraumatic stress disorder in children. Journal of Child 

and Adolescent Ps!~clii~t~y Nursing, 13,110-177. 

15.Weick,A. (1992). liuildinga su-enadis perspective for social 

work. In D. Saleebey (Ed.), The strength perspective in 

social work practice (pp. 18-26). White Plains, NY: 

Longman Publishing Group. 

16.Rynemon, E.K. (2001). Retelling violent death. Philadelphia, 

PA: Bmnner-Roudedge. 

17.Nader, K. (1997). Childhood traumatic loss: The interaction 

of trauma and grief. In C. Figley, B. Bride & N. Mazza 

(Eds.), Death and trauma: The truamatolow of grieving 

(pp.17-39). Washington, DC: Taylor and Francis. 
NC-PTSD Clinical Quarterly 

SALLOUM 

18.Pynoos, R.S. & Nader, K. (1990). Children's exposure to 

violence and traumatic death. Psychiatric Annals, 20,334- 

344. 

19. Dubrow, N. & Nader, K. (1999). Consultation amidst 

trauma and loss: Recognizing and honoring differences 

among cultures. In K. Nader, N. Dubrow, & B.H. 

Stamm (Eds.), Honoring differences: Cultural issues in 

the treatment of trauma and lass (pp. 1-19). Philadelphia, .-

PA: B1unne1-/Mazel. 

20. Thompson, M.T. & Vardaman, P.A. (1997). The role of 

religion in coping with die loss of a family member to 

homicide. Journal of the Scientific Studv of Reliaions, 

36,44-51. 

21. Nader, K., Pynoos, R., Fairbanks, L. &Frederick, C. (1990). 

Cliildi'en's F'TSD reactions one year after a sniper attack 

at their scliool. American Iournal of Psvcliiat~y, PJ, 

1526-1530. 

22. Lewis, M.L. (1996). Trauma reverberates: psychological 

evaluation of the caregiving environment of young 

children exposed to violence and traumatic loss. InJ.D. 

Osofsky & E. Fenichel (Eds.), Islands of safety^ 

Assessing and treating young victims of violence (pp. 

21-28). Arlington, VA: Zero to Three/Center for 

Clinical Infant Programs. 

23. Zeanah, C.H. & Scheeringa, M. (1996). Evaluation of 

posttraumatic syrnptomatology in infants and young 

children exposed LOviolence. In J.D. Osofsl~ & E. 

Volume 11(4) 2002 

30. Raphael, B. & Martinek,N.(1997). Assessing traumatic 

bereavement and posttraumatic stress disorder. In J.P. 

Wilson & T.M. Keane (Eds.), Assessing psycholo~ical 

trauma and PTSD (pp. 373-3951, New York: Guilford 

Press. 

31. Colien, J. A,, Mannarino, A.P,, Padlo, S.,& Shipley, C. (2002). 

Childhood traumatic grief: Concepts and controversies. 

Trauma. Violence. and Abuse, 4,307-327. 

32. Colien, J.A. (1998). Summary of the practice parameters 

for the assessment and treatment of children and 

adolescents wid1 posmu~natic stress disorder, 

of the American Academy of Child and Adolescent 

Psychiatry, 3,307-327. 

33. Scheeringa, MS., Zeneali, C.H., Drell, M.J., &Lameu, J.A. 

(1995). Two approaches to diagnosing postmumatic 

stress reactions in infancy and early childlioocl. Jurm! 

of American Academy of Child and Adolescent 

Psychiatry, 34,191-200. 

34. Scheeringa, M.S. & Gaensbauer, T.J. (2002). Posttraumatic 

stress disorder. In C.H. Zeanah (Ed)., Handbook of 

infant mental health (2nd ed.) (pp. 369-3811, New York: 

Guilford Press. 

35. Eth, S. & Pynoos, R.S. (1994). Children who witness the 

liomicide of a parent. Psychiatry, 57,287-306. 

36. Pynoos, R. & Nader, K. (1988). Psychological first aid and 

treatment approach to children exposed to community 

violence: Research implications. Journal of Traumatic 

Fenichel (Eds.), Islands of safety: Assessing and treatins ;,
 4,445-473. 


young vi0iln.s of violence (pp.9-14). Arlington, VA: Zero 

to Three/Center for Clinical Infant Programs. 

24. Terr, L.C. (1991). Childhood traumas: An outline and 

ovewiew. Anierican lo~~rnal of Psychiatry, B, 10-20.

25. Silvernun, P.R. & Worden, WJ. (1992). Children's reactions 

in die early months after the death of a parent. American 

Journal of Orthopsychiaq, @,93-104. 

26. Malmquist, C.P. (1986). Children who witness parental 

murder: Posttraumatic aspects. Journal of die American 

Academy of Child Psychiatry, 25,320-325. 

27. Rynearson, E.K. &McCreery, J. (1993). Bereavement after 

homicide:A synergism of trauma and loss. American 

Journal of Psychiatry, m,258.261. 

28.Thompson,N., Noms F. & Ruback B. (1998). Comparative 

distress levels of inner-city family members of homicide 

victims. Journal of Traumatic Stress, a,223-242. 

29. Murphy, S.A., Braun, T.,Tillery, L. Cain, K.C Johnson, 

C.L. & Beaton, R.D. (1999). PTSD among bereaved 

parents following die violent death of their 12-to 28- 

year old children: A longitudinal prospective analysis. 

Journal of Traumatic Stress, 12,273-291. 

37. Hardwick, P. J. & Rowton-Lee, M.A. (1996). Adolescent 

homicide: toward assessment of risk. Journal of 

Adolescence, 12,263-276. 

Alison Salloum, LCSW is Senior Clinical Advisor with Project LAST (Lossand Survival Team) 

at Children's Bureau of New Orleans, Inc 

Project LAST provides community-based services to children and families after violent death, 

as well as to child witnesses and victims of violent crimes. Ms. Salloum is working on her doctorate in social work at Tulane University