CLINICAL QUARTERLY 


MANAGEMENT OF PANIC IN VETERANS 


WITH POST-TRAUMATIC STRESS DISORDER 


Annabel Prins, Ph.D. and PamelaJ. Swales, Ph.D. 


Twenty-eight to 55 percent of veterans with post-traumatic stress 

disorder (PTSD) will also meet diagnostic criteria for panic disorder or panic 

disorder with agoraphobia (1,2). This complex and usually chronic symptom 

presentation has led to the development of innovative treatment programs 

that combine exposure and cognitive processing treatment for PTSD with 

panic control treatment for Panic Disorder (PD) (3). The success of these 

Ã‘Ã‘Ã‘Ã 

Annabel Prins 

combined treatments with civilian crime victims appears quite promising (4). To 

date, there has been no systematic investigation of the treatment of PTSD with PamelaJ.Swales 

comorbid panic attacks in veteran populations. 

Panic control treatment (PC? is an empirically-supported treatment developed in the 1980's by David 

Barlow.and his associates (5). PCT begins with a strong psycho-education component that delineates the 

difference between types of anxiety and panic attacks. It places special emphasis on how these negative 

emotional states differ across the three major response channels (it., physical, cognitive, and behavioral). 

The second step introduces the patient to the role of hyperventilation in producing panic sensations. It 

also provides instruction in breathing retraining and relaxation. (It should be noted that the importance 

of this step has recently been questioned (5)). The third step in PCT is to identify and challenge distorted 

beliefs about anxiety and panic. The two types of cognitive distortions most often challenged are 

catastrophic thinking and probability overestimation.. The fourth step involves interoceptive exposure. 

This involves repeated exposure to anxiety-provoking internal sensations (e.g., pounding heart, sweating, 

numbness). For those patients with agoraphobia, the last phase of treatment involves in-vivo exposure 

(i.e., graduated exposure to what is being avoided), and interoceptive exposure combined with in-vivo 

exposure. Detailed PCT manuals are available for both the patient and the therapist (6,7). Perhaps the 

most comprehensive and up-to-date manual is entitled, Mastery of Your Anxiety and Panic MAP-3) (7). 

Over the past 5 years we have implemented an abridged form of panic control treatment in both 

our inpatient and outpatient PTSD treatment programs for male and female veterans. PTSD in these 

veterans is complex and chronic with frequent psychiatric and medical comorbidities. In addition to 

comorbid panic attacks and PD, the most frequent and common comorbidities are depression, substance 

abuse, chronic pain, diabetes, and hypertension (8-10). Consequently, treatment for these veterans is 

often multi-modal and includes medications, trauma-focused individual or group therapy, and participation 

in relapse prevention programs. 

Continued on page 35 
NC-PTSD Clinical Quarterly Volume 11 (3) 2002 

Adjusting to the "new normal" is challenging, particularly when "normal" isn't really established. The impending war with 

Iraq (at press time), the uncertainty of the war's impact on global affairs, and the recent warnings by the Homeland 

Security Advisory System urging citizens to prepare for a biological attack have combined to raise anxiety to new levels. 

Veterans and the general population are asking: 'What do I do for my family, and myself?" Similarly, clinicians are asking: 

"What do I do for my clients, patients, my family, and myself?" Rather than attempt to summarize coping strategies in this 

limited space, I thought it might be helpful to list a few internet pages (of many) that represent current thinking about coping 

and have a future issue feature a detailed article. 

Websites for Clinicians Websites for the general population 

National Center for PTSD American Psychological Association 

"How terrorist acts may affect veterans" "Coping with terrorism" 

http://\v\v\v.ncptsd.org/facts/disasters/fs_vetems_disaster.html http://helping.apa.org/daily/terrorism.html" 

"Coping with PTSD and recommended lifestyle changes for PTSD 

patients" National Mental Health Association 

http://www.ncptsd.org/facts/treatment/fs_coping.html" "Living your life during terrorist threats and other challenging times" 

http://www.nmha.org/reassurance/terrorism,cfm 

'Terrorists attacks and children" 

http://www.ncptsd.org/facts/disasters/fschildrendisaster,html 'Tips for older adults" 

http://www.nmha.org/reassurance/olderaduktips.cfm 

National Institute of Mental Health 

'What are scientists learning about trauma in children and adolescents?' 


http://\v\v\v.nimh.nih.gov/publicat/violence.cfm#viol6 

Bruce H. Young, Editor-in-Chief 

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 Behavioral Science Division Women's HealthScienceDivision 

Fred Gusman, M.S.W, Director Terence Keane,Ph.D., Director Lynda King, Ph.D., Acdng Director 

VAMC, Palo Alto, California 94304 VAMC, Boston, Massachusetts 02130 VAMC, Boston, Massachusetts 02130 

Pacific Islands Division Neuroscience Division Northeast ProgramEvaluation Center 

Fred Gusman, M.S.W., Chief of Operations John IGystal, M.D., Director Robert Rosenheck, M.D., Director 

Honolulu, Hawaii 96813 VAMC, West Haven, Connecticut 06516 VAMC, WestHaven,Connecticut 06516 

Clinical Quarterly Staff 

Editor-in-Chief Bruce H. Young, L.C.S.W. 

Managing Editor Josef I. Ruzek, Ph.D. 

Executive Editor Fred D. Gusman, M.S.W. 

Associate Editors Eve B. Carlson, Ph.D., Ilona Pivar, Ph.D., & Rohyn Walser, Ph.D. 

Assistant Editor John Aboytes, B.A. 

Design &Production Bruce H. Young 

- 1 

Please fed free to contact us nr the Education Division: FTS 463.267312494; commercial number 650-493-5000 cxt. 22673122494; or E-mail: ncptsd@bruccyoung.net 

Please address nil correspondence to: Editor, National Ccnicr for PTSD Climcn! Quarterly,VA Palo Alto Hcakh Can; System, 795 Willow Rd (352E117). Mcnio Park, CA 94025 
NC-PTSD Clinical Quarterly 

As providers of PCT, our focus has been on panic 

attacks (trauma-cued and non-trauma-cued), anxious 

apprehension, generalized anxiety, and selected avoidance 

behaviors. We have found that this specific focus on panic 

and anxiety can bring about symptom relief without 

negatively impacting the complicated relationships veterans 

can have with their PTSD diagnosis (e.g., service connection, 

identity tied to military trauma). In this article, we address 

our experiences modifying and applying PCT in this 

population. 

Step 1: Psychoeducation and Assessment 

At the heart of this initial phase of treatment is a 

clear description of what is and what is not panic, and the 

importance of self-monitoring panic attacks and anxiety 

experiences. (The MAP-3 manual provides detailed 

descriptions of typical panic attack symptoms, typical 

agoraphobic situations, typical ways of coping and several 

self-monitoring forms.) Because our patient population 

experiences trauma-cued panic attacks, we have modified 

the panic attack record to reflect these events. As may be 

expected with complex PTSD, we have also found that our 

population has significant problems with attention, sustained 

concentration, abstraction, memory, and reading ability. - Consequently, we work hard to use terminology and concepts 

that are readily understandable. For example, although we 

The review of sensations ... 
 is often the first time that 


patients realize that certain 


sensations associated with panic 


and anxiety (e.g. lightheadedness 


or feeling "spacey") can be 


created and produced. 


talk about cognitive, physical, and behavioral responses 

during a panic attack or while anxious, we often use terms 

like "think", "feel" and "do". We also spend additional 

time on evaluating each veteran's understanding of basic 

concepts (e.g., having patients provide a summary of what 

they know about panic and anxiety). 

Volume 11 (3) 2002 

MANAGEMENTOF PANIC IN VETERANS WITH PTSD 

Our first goal is to be confident that patients are 

able to identify different types of panic attacks (e.g., 

trauma-cued, situational, unexpected, reality-based) and 

that they can distinguish generalized anxiety (we call it 

"worry") from anxious apprehension (we call it worry 

about having panic attacks or their consequences). Our 

second goal is to be confident that patients understand 

the normal and functional significance of anxiety (we often 

call it "readiness") and panic attacks (we call it "fight or 

flight"), 

Our awareness and modification of PCT to our 

population's cognitive challenges has also been extended 

to our assessment process. We have found that many of 

the instruments used in outcome studies are too long and 

utilize language that is too difficult for our patient 

population (e.g., "palpitations", "tachycardia", 

"depersonalization"). After careful review of existing 

measures, we have found the following questionnaires to 

be psychometrically sound, quick to administer, easy to 

read, "patient-friendly" and clinically useful (i.e., they 

provide clear targets for treatment): (a) the Body 

Sensations Questionnaire (10); (b) the Cognitions 

Questionnaire (10) and; (c) Mobility Inventory (11). 

Step2: Hyperventilation and LearningPhysical Control 

We start this step by having patients count the 

number of breaths they take in one minute. We 

observe differences in rate and generate hypotheses 

about why such differences exist (e.g., weight, 

medications, coffee consumption, etc.). Next, we have 

the patients purposefully "over breathe" (i.e., 

hyperventilate) for about one minute. We participate 

in this exercise ourselves and encourage patients to go 

beyond the point of being comfortable. The review 

of sensations that follows is often the first time that 

patients realize that certain sensations associated with 

panic and anxiety (e.g. lightheadedness or feeling 

"spacey") can be created and produced. It also 

provides an opportunity to conceptualize these 

sensations as unpleasant rather than something to be 

feared. This recognition is, of course, the goal of the 

exercise. We make sure to comment on our sensations 

so as to normalize their experience and we make sure 

to identify other physical experiences that are 

profoundly unpleasant but typically not feared (e.g., a 

cramp in one's leg, headaches, etc). 
NC-PTSD Clinical Quarterly 	 Volume 11 (3) 2002 

PRINS & SWALES 

We have consistently found that an elaborate 

explanation of breathing physiology is not needed and 

that the information provided in the MAP-3 manual on 

this topic can be difficult to understand by all but a few 

(e.g., military nurses, medics). We have also found that 

most of our patients have at least some familiarity with 

diaphragmatic breathing and relaxation training (these are 

often topics covered in other parts of their treatment). 

Although we do practice "slowed" breathing and, time 

permitting, progressive muscle relaxation in-session, we 

are careful to point out that learning how to control one's 

bodily responses does not mean that their bodily responses 

are dangerous. In other words, we don't want to provide 

them with a technique that perpetuates avoidance of A 


feared internal stimuli. 

It is worth noting that we have observed 

relaxation-induced anxiety in quite a few of our patients. 

This is especially true for patients who survived their 

traumatic experiences through sustained hypervialance. 

For these patients, the state of being relaxed is associated 

with an increased risk for re-traumatization. We explicitly 

recognize this possibility, and encourage the careful 

examination of why this may have been functional in the 

past but not now. If it is determined that the relaxationinduced anxiety is the result of an increased focus on 

physical sensations and fear of these sensations, relaxation 

and/or breathing retraining is added to the list of 

interoceptive exposure exercises (see below). 

Step 3: Cognitive re-structuring 

In addition to the classic cognitive beliefs 

associated with panic disorder and included in the 

Agoraphobic Cognitions Questionnaire (e.g., "I'm going 

to die, throw-up, pass out, lose control," etc.), there are a 

few beliefs that appear to be unique to this population. 

For example, there is often a fear that "losing control" 

will mean seriously hurting others. This makes sense in 

light of military training that emphasizes "fight" rather 

than "flight". There are also beliefs (observed to be more 

common in our female veterans), that a panic attack will 

lead to a prolonged dissociative or flashback episode. 

We challenge these beliefs in the same way we do other 

predictions regarding panic. 

As mentioned in the introduction, the two types 

of cognitive distortions most frequently encountered in 

panic disorder are probability overeidmation and catastrophic 

catastrophic thinking. Probability overestimation is 

reflected in statements that over-predict the likelihood 

of something bad happening (e.g., "I am going to die;" 

' I am having a stroke"). Catastrophic thinking is 

reflected in statements that describe an event or experience 

as awful, dangerous, insufferable or catastrophic when it 

is not. Examples of this include statements like, "Other 

people might notice my anxiety and that would be awful" 

or "The symptoms of anxiety are too unbearable." Often 

the catastrophic cognition is predicted with certitude. 

Challenging these catastrophic and overpredictive cognitions requires regular and careful attention 

to facts. We have found the following challenges and 

statements useful in our work: 

1. 	 "How many times have you felt this 


way.. .and how many times has the feared 


outcome occurred?" 


2. "What are the real chances of this 


outcome occurring?' 


3. 	 'mat is the evidence for and against this 


prediction?' 


4. 	 "Just because you feel frightened (e.g., or 


just because you feel your heart beating 


fast) does not mean you are at an increased 


risk for .....(a feared outcome)." 


5. 	 'You can cope with this attack because 


there is no real danger." 


6. 	 "Panic attacks are time-limited and 


manageable." 


7. 	 "It does feel awful doesn't it? But so what 


if you are uncomfortable or anxious for 


awhile?" 


We have found it very important to validate and normalize 

panic responses to truly dangerous situations in their past 

while, simultaneously, facilitating an understanding and 

acceptance of current symptoms as not dangerous or 

insufferable, and not indicative of actual or impending 

danger. 
NC-PTSD Clinical Quarterly Volume 11 (3) 2002 

MANAGEMENT OF PANIC IN VETERANS WITH PTSD 

Step 4: Interoceptive exposure 

Because so many unexpected panic attacks are 

triggered or cued by internal sensations, this step is critical 

to PCT. In order to identify sensations that are potentially 

frightening (i.e., those most similar to what is experienced 

during a panic), we review the veterans' responses to the 

Body Sensations Questionnaire. We then introduce the 

concept of exposure as a treatment component often by 

making reference to how specific phobias are treated. In 

other words, we talk about the value and importance of 

experiencing the feared situation (here, physical 

sensations) repeatedly and long enough so that one can 

learn that the physical sensations are not harmful 

(habituation). We then provide various opportunities for 

repeated exposure trials that create physical sensations 

that mimic those experienced (and feared) during high 

anxiety and panic attacks. Exposure trials include 

breathing through a straw, running in place, spinning in a 

chair, stair climbing, and fast walking in the halls. 

Although the VA is moving toward empiricallysupported treatments for anxiety disorders (12), there is often 

a need to share the rationale for this component of the 

treatment with staff as well as patients. This consideration 

may be particularly true in residential or inpatient programs. 

On rare occasions, we have encountered some patient 

resistance to these exercises, and on occasion, medical contraindicators. However, our greatest obstacle has been 

obtaining the support of other health care providers. Most 

health care providers view panic as something that has to be 

controlled 0.e. prevented). Although they are familiar with 

methods that decrease arousal or panic (e.g., medications, 

relaxation training) they are unfamiliar with the rationale and 

principles of interoceptive exposure. Indeed, interoceptive 

exposure is often viewed as something that could induce 

dissociation or some other trauma-related flashback, and 

consequently something to be avoided. 

In five years, we have never experienced a problem 

subsequent to interoceptive exposure exercises. This is not 

to say that trauma-related memories have not surfaced. Our 

emphasis, however, has focused on teaching the veteran, by 

personal experience, that one does not have to be afraid of the 

physical sensations associated with high anxiety or panic attacks. 

Almost without exception, veterans report that these exercises 

are of great value in enabling them to break the automatic 

connection between physical sensations and feared outcomes. 

Step 5: In-vivo exposure 

Usually, this last step is not formally targeted 

in residential or inpatient settings. We do not have the 

opportunities to provide therapist-assisted in-vivo 

exposure "off the unit." However, the nature and 

structure of the inpatient program provides frequent 

naturalistically-occurring opportunities to confront 

situations (e.g., interpersonal conflict, meetings, 

classroom situations, medical examinations and 

procedures) that are often avoided because of fear and 

anxiety. Thus there are opportunities to experience 

and confront anxiety and panic symptoms. Patients 

may also submit "weekend passes" for treatment team 

approval. If granted, these often provide for additional 

exposure experiences. 

In outpatient settings, there is consideration of 

what daily activities are avoided in order to minimize 

physical sensations (e.g., coffee, exercise) as well as 

more typical agoraphobic situations included in the 

Mobility Questionnaire (e.g., shopping malls, 

restaurants, etc). A hierarchy of feared sensations and 

situations is created and patients are paired with a peer 

to complete designated graduated exposure exercises. 

(This has the added benefit of limiting social isolation 

in this population). Many of these exercises will include 

purposeful creation of physical sensations in avoided 

situations (e.g., standing in line after drinking coffee 

or exercising). We've had a number of veterans who 

were severely agoraphobic return to active recreational 

and occupational pursuits. 

Conclusion 

In this article we have identified a few ways in 

which we modified PCT for a veteran population with 

cornorbid PTSD and panic attacks. We also reviewed 

several considerations for the effective implementation 

of PCT as a distinct component of comprehensive 

PTSD services. Our clinical experience with PCT for 

this population has been very favorable. Indeed, we 

believe that the increased tolerance for anxiety and 

panic obtained through PCT can generalize to other 

negative emotional states. In other words, PCT seems 

to facilitate acceptance of a broad range of negative 

emotions and this acceptance, in turn, helps patients 

to approach trauma-related material. 
NC-PTSD Clinical Quarterly 

PRINS & SWALES 

References 

1. Orsillo, S.M., Weathers, F.W.,Litz, B.T., Steinberg, H.R., 

Huska, J.A., & Keane, T.M. (1996). Current and 

life-time psychiatric disorders among veterans with 

war-zone related posttraumatic stress disorder. 

Journal of Nervous and Mental Disease, I& 307-

313. 

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

Flores, L.P. &Manes, FJ. (1992). Phenomenology 

and course of psychiatric disorders associated with 

combat-related posttraumatic stress disorder. 

American journal of Psychiatq, M, 1568.1574, 

3. Falsetti, S.A. (1997). Treatment of PTSD with comorbid 

panic attacks. National Center for PTSD Clinical 

Ouarterly. 7,46-49. 

4. Falsem, S.A., Resnick, H., Davis, J., & Gallagher, N.G. 

(2001). Treatment of posttraumatic stress disorder 

with comorbid panic attacks: Combining cognitive 

processing therapy with panic control treatment 

techniques. Group Dynamics, 5, 252-260. 

5. Barlow, D.H. (2002). Anxiety and its disorders: The 

nature and treatment of anxiety and panic (Second 

edition). New York: Guilford Press. 

6. Barlow, D.H., & Craske, M.G. (2000). Mastery of vow 

anxiety and panic (MAP-3): Client workbook for 

anxiety and panic (3"' ed.). San Antonio, TX: 

Graywind/Psychological Corporation. 

7. Craske, M.G., Barlow, D.H., & Meadows, E. (2000). 

Mastery of vow anxietv and panic: Therapist mide 

for anxiety, panic. and ae-oraohobia (MAP-3). San 

Antonio, TX: Graywind/Psychological Corporation. 

8. Kessler, R.C., Sonnega, A,, Broment, E., Hughes, M., & 

Nelson, C.B. (1995). Posttraumatic stress disorder 

in the National Comorbidity Survey. Archives of 

General Psychiatry, 52,1048-1060. 

Volume 11 (3) 2002 1, 

9. 	 Frayne, S., Skinner, K.M., Sullivan, L.M., Tripp, TJ., 

Hanldn, C.S., Kressin, N., & Miller, D. (1999). 

Medical profile of women VA outpatients who 

report sexual assault while in the military. 

of Women's Health, 8, 835-845. 

10. Chambless, D.L., Caputo, G.C., Bright, P., et al. (1984). 

Assessment of fear in agoraphobics: The body 

sensations questionnaire and the agoraphobic 

cognitions questionnaire. Journal of Consulting 

and Clinical Psvcholog, 52, 1090-1097. 

11. Chambless, D.L., Caputo, G.C., Jasin, S.E., Gracely, 

E.J., & Williams, C. (1985). The mobility inventory for agoraphobia. Behavior Research and 

Therapy. 23,35-44. 

12. Vye, C., Leskela, J., Rodman, J., Olson, D., & Mylan, 

M. (2001). Development of an anxiety clinic within 

a Veterans Administration Medical Center. 

Behavior Therapist, 24, 49-56. 

Annabel Prins, Phd. is part of the Education 

Division of the National Center for PTSD and 

an assistant professor in the department of 

psychology at San Jose State University. Her 

clinical interests are in the assessment and 

treatment of anxiety disorders, especially in male 

and female veterans. Her current research focuses 

on the detection of PTSD in primary care. 

Pamela Swales, Ph.D. is a Research Health 

Science Specialist at the National Center for Posttraumatic Stress Disorder, Education Division 

in Men10 Park, CA. Her clinical and research 

interests are the anxiety disorders, with emphasis on Panic Disorder and PTSD. For the last 

several years, she has focused her clinical and 

research efforts to address effective CognitiveBehavioral treatment interventions for comorbid 

panic and PTSD. 
NC-PTSD Clinical Quarterly Volume 11 (3) 2002 1 SUBSCRIPTION INFORMATION 

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NC-PTSD Clinical Quarterly Volume 11 (3) 2002 

Hippocampal volume in PTSD 

A number of hrain imaging studies have detected smaller hippocampal volume among subjects diagnosed with PTSD. 

Utilizing structural magnetic resonance imaging (MRI), Doug Bremner and colleagues (1) at die Clinical Neurosciences Division 

of the National Center for PTSD were the first to report this abnormality among combat veterans. Independent replications of 

this finding have been described with combat-related and childhood sexual abuse-related PTSD in three additional reports (2-4). 

In addition to these MRI reports, consistent results have come from two magnetic resonance spectroscopy (MRS) studies 

which have utilized die amino acid N-acetyl aspartate (NAA), a histochemical marker for the density and viability of neurons in 

the brain. In both, veterans with PTSD exhibited lower NAA levels in hippocampus (5) and medial temporal lobes (where the 

hippocampus and other key structures are situated) (6), although the former finding was only marginally significant. In no case 

was PTSD associated with either larger hippocampal volume or higher NAA levels in that region of the brain. 

This result has had a major influence on the scientific and clinical communities as well as on the general public. It appears to 

be that there is a significant difference in brain structure that distinguishes individuals with PTSD from non-affected individuals. 

Therefore, it suggests that chronic PTSD meets the National Alliance for 'Mental Illness criterion for "a chronic brain disorder" 

along with depression and schizophrenia. Most importantly, as with any important scientific finding, it has raised a number of 

important questions, stimulated provocative scientific speculation, and generated additional research. One of the more intriguing 

hypotheses has been that PTSD-related abnormalities in the liypotlialamic-pituitary-adrenal (HPA) system might be responsible 

for reducing the volume of die hippocanipus (7). Two arguments in support of that speculation are: a] that stress-induced 

activation of HPA mechanisms in animals have been shown to produce atrophy of hippocampal neurons and defoliation of 

hippocampal dendrites (8) and b] that HPA-related reduction of hippocanipal volume has been demonstrated in humans affected 

with Cushing's Disease and Major Depressive Disorder (9). 

Recent research findings have specifically addressed the chicken-or-egg question generated by the previous studies. As 

explicated by Roger Pitman and colleagues (10) the questions are: did PTSD-related HPA abnormalities shrink the hippocampus of 

affected individuals or were people with smaller hippocampi more likely to develop PTSD in the first place? The cross-sectional 

studies, previously mentioned, cannot help us answer these important questions. 

Roger Pitman has been one of the most thoughtful and creative investigators to tackle this problem. Through a twin study 

and a prospective longitudinal investigation, he and his colleagues have shown that smaller hippocampal volume is more likely a 

risk factor than a cause of PTSD. Utilizing a case-control design he conducted MRI assessments in which the hippocampi of 

combat exposed Vietnam veterans with and without PTSD were compared with their respective monozygotic twins who had not 

been exposed to Vietnam War trauma and who did not have PTSD (11). These investigators found smaller hippocampi in both 

the trauma-exposed twins with severe PTSD and in their unexposed non-PTSD identical twin brothers. In contrast, non-PTSD 

combat-exposed twins had larger hippocampi, as did their non-exposed monozygotic twin brothers. These findings clearly 

demonstrate that PTSD does not "shrink" the hippocampus and strongly suggest that smaller hippocampi among affected individuals preceded combat exposure, since non-exposed, non-PTSD twin brothers also had small hippocampi. Since monozygotic 

hvins reared in the same household share the same environment as well as the same genes, these studies cannot, by themselves 

tease apart the unique contributions of these two factors. Further studies with &ygotic twins (who share the same environment 

hut only some of die same genetic material) or from monozygotic twins reared apart, will be needed to address the nature vs. 

nurture question that remains to be addressed. 

The second investigation (12) is a longitudinal study of 37 subjects exposed to a traumatic event, serious enough to generate an 

emergency room visit. MlU assessment of the hippocampus was carried out on all subjects within one week of die traumatic event 

and six months later, at which time 10 had PTSD and 27 did not. Hippocampal volume remained stable for both groups over this 

six-month interval, suggesting that progressive reduction of the hippocampus was not associated with the development of PTSD 

during this initial interval. Again, these results are suggestive rather than conclusive since it may take more than six months to 

produce such changes in hrain structure or it may take more prolonged stress at an earlier developmental stage (as in chronic 

physical or sexual, child abuse) or there may be other brain structures, rather than hippocampus, that deserve our attention. 
NC-PTSD Clinical Quarterly 	 Volume 11 (3) 2002 

Indeed, the work of Michael DeBellis and others (13) with children and adolescents afflicted with maltreatment-related PTSD, 

suggests that we may need to look elsewhere to appreciate the impact of PTSD on brain structures. In comparison with control 

subjects, these children did not exhibit any reduction in hippocampal volume. Anatomical MRI brain scans, however, revealed 

significant reductions in intracranial, cerebral and prefrontal cortex, prefrontal cortical white matter, right temporal lobe volumes, 

and several areas of the corpus callosum. In addition, PTSD subjects exhibited larger frontal lobe cerebrospinal fluid volumes 

Aim control subjects. Preliminary research by Joan Kaufman at the National Center's Clinical Neurosciences Division appears to 

have independently replicated DeBellis' observations of reduced volume of medial and causal sections of the corpus callosum 

among maltreated children and adolescents with PTSD. These findings strongly suggest that brain development is adversely 

affected by maltreatment-related PTSD. 

As for traumatized adults, Canive and associates (14)observed focal lesions of white matter in combat veterans with PTSD but 

not hippocampal abnormalities. A recent study by Fennema-Notestine and associates (15) with female victims of intimate partner 

violence reported findings similar to those obtained by DeBellis, mentioned previously. Indeed, the observed reduction in the 

volume of supratentorial cranial vaults and in frontal and occipital gray matter correlated with die severity of childhood physical 

abuse, but not with either the severity of adult intimate partner violence or with the presence or absence of PTSD. 

To summarize, results from structural brain imaging suggest that anatomic abnormalities may be more likely to result from 

childhood than. from adult trauma. They also suggest that we need to focus our attention on other brain structures besides the 

hippocampus to get a more complete picture of the potentially deleterious impact of PTSD on brain structures. Finally, it is 

important to recognize that I have restricted this brief review to anatomic studies because I wanted to focus primarily on the 

hippocampal volume controversy. Very interesting data can also be found in studies of functional brain imaging that show 

marked abnormalities in regional cerebral blood flow of PTSD vs. non-PTSD subjects. Discussion of these findings will have to 

take place in a future column. 

References 


I Bremner, J.D., Randall, P., Scott, T.M., Bronen, R.A., Seibyl, J.P., Southwick, S.M., Delaney, R.C., McCarthy, G., Charne?, 


D.S., & Innis, R.B. (1995). MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic 

stress disorder. American Iournal of Psvchiatq, m,973-981. 

2. 	 Brcmner, J.D., Randall, R., Vermetten, E., Staib, L., Bronen, R.A., Mazitre, C., Capelli, S., McCarthy, G., Innis, R.B., & 

Charney, D.S. (1997). MRI-based measurement of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abusc: A preliminary report. Bioloeical Ps~chiatry, a,23-32. 

3. 	 Gurvits, T.V., Shenton, M.E., Hokama, H., Ohta, H., Lasko, N.B., Gilbertson, M.W., Orr, S.P., Kikinis, R., Jolesz, F.A., 

McCarley, R.W,, & Pitman, R.K. (1996). Magnetic resonance imaging study of hippocampal volume in chronic combatrelated posttraumatic stress disorder. Biolo~ical Ps~chiatry, a,1091-1099. 

4. 	 Stein, M.B., Koverola, C., 1-Ianna, C., Torchia, M.G., & McClarty, B. (1997). Hippocampal volume in women victimized by 

childliood sexual abuse. Ps~cl~oloeicalMedicine, 27, 951.959. 

5. 	 Schuff, N., Marmar, C.R., Weiss, D.S., Neylan, T.C., Sclioenfeld, F., Fein, G., & Weiner, M.W. (1997). Reduced hippocanipal 

volume and n-acetyl aspartate in posttrau~natic stress disorder. Annals Ne\v York Acaden~v of Science, &l,516.520. 

6. 	 Freeman, T.W., Card-well, D., Karson, C.N., & Komorski, C.N. (1998). In vivo proton magnetic resonance spectroscopy of the 

niedian temporal lobes of subjects with combat related posttraumatic stress disorder. Magnetic Resonance in Medicine, 40, 66-71. 

7. 	 Yehnda, R. (1999). Linking the neuroendocrinology of post-traumatic stress disorder with recent neuroanatomic findings. 

Seminars in Clinical Neuro~svchiatr~, 4 256-265. 

8. McE~ven, B.S. (1999). Stress and hippocampal plasticity. Annual Rcvic\v of Neuroscience, 22, 105-122, 

9. Sapolsky,RM. (2000). Glucocorticoidsandhippocampalatrophyinneuropsychiatucdisorders.Archivesof GeneralPsvchiatry, 57,925-935. 

10. 	 Pitman, R.K., Shin, L.M., & Rauch, S.L. (2001). Investigating the pathogenesis of posttraumatic stress disorder with neuroimaging. 

Journal of Clinical Psychiatry, 62 (Suppl. 17), 47-54. 

11. 	 Gibertson, M.W., Shenton, M.E., Ciszewski, A,, Kasai, K., Lasko, N., Orr, S.P., & Pitman, R.K. (2002). Smaller hippocanipal 

volume predicts pathologic vulnerability to psychological trauma. Nature Neuroscience, 5, 1242-247. 

12. 	 Bonne, O., Brandes, D., Gilboa, A., Gomori, J.M., Shenton, M.E., Pitman, R.K., Shalev, A.Y. (2001). Longitudinal MRI study 

of liil~pocampal volume in trauma sun~ivors with PTSD. American lournal of Psvcl~iatry, m, 1248.1251. 

13. 	 DeBellis, M.D., Keshavan, M.S., Shifflett, H., lyengar, S., Beers, S.R., Hall,J., & Motitz, G. (2002). Brain sinictures in pediatric maltreatmentrelated posttraumatic stress disorder: A sociodeniographically matched study. Biological Psvchiatry, 52, 1066-1078. 

14. 	 Canive, J.M., Lewine, J.D., Orrison, W.W.,Edgar C.J., Provencal, S.L., Davis, J.T., Paulson, I<., Greeber, D., Roberts, B., 

Escalona, P.R., & Calais, L. (1997). MRI reveals gross structural abnormalities in PTSD. Annals New York Academy of 

Scicnce. 821, 512-515, 

15. 	 Fennema-Notestine, C., Stein, M.B., Kennedy, C.M., Archibald, S.L., & Jernigan, T.L. (2002). Brain morphometry in female 

victims of intimate partner violence with and \vithout posttra~~matic stress disorder. Biolo~cal Ps"chiatry, 3,1089-1101. 

41 
NC-PTSD Clinical Quarterly Volume 11 (3) 2002 

The role of self-defense training in preventing sexual revictimization 

Annabel Prins, Ph.D., NC--PTSD, Education & Clinical Laboratory Division, Medo Park, CA; Claire Sandringham, M.S., 

Marriage &Family Intern, Family & Children's Services, San Jose, CA; &Julie Weidauf, Ph.D., VA Sierra-Pacific MIRECC. 

In a recently published meta-analysis, a definite relationship was found between childhood experiences of sexual abuse 

(CSA) and adult experiences of sexual assault (1). Although the 19 studies included in this review utilized only civilian samples, 

the relationship appears to hold for active-duty and veteran women as well. For example, Merrill et al., (2) found that female 

Navy recruits who were sexually assaulted in adulthood were 5 times more likely to have a history of CSA than recruits without 

this history. Coyle et a]., (3) found that over 50% of female veterans with a history of childhood abuse reported abusive 

experiences in adulthood. Clearly, there is a need for interventions that actively and directly target sexual revictimization. 

To date, most well established and empirically-supported treatments for abuse or assault-related post traumatic stress 

disorder (PTSD) have not included a prevention component (4). Instead, the majority of these treatments have focused on 

ameliorating PTSD symptoms through prolonged exposure or through a systematic restructuring of beliefs associated with the 

trauma. Although some treatments do introduce "coping skills" (e.g., training in relaxation or breathing), the focus is on 

managing past and present feelings, not future interpersonal behaviors. It may not be surprising that these empirically supported 

treatments have been most effective in reducing re-experiencing and hyperarousal symptoms of PTSD and less effective in 

reducing detachment and numbing symptoms. 

In contrast to these research-based "treatment" protocols, community-based rape crisis centers have a long history of 

providing self-defense classes as a rape prevention strategy to CSA survivors. Although these classes can vary tremendously 

with regard to frequency of contact, length of practice, instructor expertise, and philosophical foundation, most include training 

in how to use body parts (e.g., knees, elbows) as "weapons" against vulnerable "targets" (e.g., eyes, groin) as well as the use of 

impromptu weapons (e.g., keys, comb). There is often a strong feminist emphasis on divorcing female status from victim 

status and developing a fighting spirit (5). Assertive use of voice and body language are also emphasized. In their review of 

self-defense programs for women, Searles and Berger cautioned against police-sponsored courses that lack individual 

empowerment, and martial-arts models that exploit women's fear of crime (6). They, like the National Coalition Against Sexual 

Assault (7) ,recommend self-defense classes that combine martial arts techniques with a feminist philosophy, and prepare 

women for acquaintance rape as well as stranger assaults. 

The effectiveness of self-defense training in preventing subsequent revictimization in CSA survivors has not been 

extensively studied. In fact, there are only a few longitudinal studies on the effects of self-defense training in general (i.e., not specific 

to CSA survivors), and these have focused on the psychological impact of the u-aining, mostly in college women. There is indirect and 

anecdotal evidence that self-defense training may be important in preventing revictimization. For example, several studies have 

found that women who have successfully avoided acquaintance rape behaved in an assertive and action-oriented manner (8,9). Matt 

Thomas, creator of the self-defense course Model Mugging, has reported that 95% of those women who were assaulted after participating 

in his course (and reported back), were able to utilize the skills taught and avoided harm (10). By far, the most empirically-supported 

and consistent finding to emerge from this literature is the psychological benefit of participating in self-defense training. For example, 

Weitlauf et al., (1 1) found that participation in self-defense training produced a generalized increase in perceptions of self-efficacy. 

More specifically, and compared to women on a wait-list, participants receiving self-defense training reported higher levels of 

physical self-efficacy as well as increased levels of general coping, self-regulatory skills, and interpersonal assertiveness. 

Preventing sexual revictimization in women with a history of CSA needs to include consideration of empirically supported risk 

factors. Amy Naugle and her associates have outlined several risk factors for revictimization (12). They include the presence of tra~imarelated symptoms as well as substance abuse. Women presenting with these risk factors may have difficulty recognizing or perceiving 

dangerous situations and/or responding to these situations effectively. Preliminary research, using videotaped scenarios of 

interpersonally risky situations, suggests that women with a history of sexual assault may be equally or more likely to perceive 

danger, but less likely to react effectively (e.g., resist a sexual advance). Training in self-defense may provide die necessary skills 

for women to respond assertively and effectively to threats of victimization. 

REFERENCES APPEAR ON PAGE 46 
- - 

NC-PTSD Clinical Quarterly Volume 11 (3) 2002 

LESSONS LEARNED FROM 9/11: CONSIDERATIONS IN THE 


DEVELOPMENT OF SCHOOL-BASED INTERVENTIONS 


FOLLOWING LARGE SCALE VIOLENCE 


The attacks on the World Trade Center World directly 

exposed over 150,000 school children within a two hour period 

to the sights, smells and sounds of the planes crashing into the 

towers followed by their collapse. Virtually all childrenin Ground 

Zero schools were personally physically exposed to one or more 

effects of the attack, including 73% who were in or near the 

cloud of smoke and dust (1). Despite the significant psychological 

distress experienced by the schoolcomn~unity, itis not surprising 

that the fourteen public schools in the Ground Zero area had 

as their top priority the practical tasks of recovering from the 

destruction of the physical environment and stabilizing functional 

capacity. Of the fourteen public schools in the Ground Zero 

area, five required evacuation. All required intensive health 

review and 

cleaning 

related to the ....only a 

pervasive minority of students had chalky dust 

that had travel- sought treatment either 

traveled within the school system or 

through air from an outside mental ducts and 

windows and health professional. 

settled on 

blackboards, 

books and computer keyboards. Clean-up operations were 

completed with remarkable speed. Even so, the last school to 

return to its home site occurred February 4,2002, nearly 5months 

after the attack. During this time, mental health intervention 

largely took the form of support and consultation to 

administrators, teachers, and parents, as well as psycho-education 

and normalization of expectable symptoms of acute trauma for 

all groups, including students. 

At the half-year anniversary of 9/11, parents and 

educators noted that there was continued and significant 

psychological distress in many students. Indeed, this observation 

was consistent with the results of a landmark study of 8000 

school children commissioned by the Board of Education 

conducted at 6-months post trauma (1).The sample was drawn 

from 94 schools, grades 4 through 12, across the entire City of 

New York, with the Ground Zero area over sampled relative 

to other geographic areas. A broad range of mental health 

problems were observed at higher than expected rates, with 

Marylene Cloitre, Ph.D. 

the most pronounced 

elevations obtained for 

posttraumatic stress disorder, 

agoraphobia, conduct 

disorder, and separation 

anxiety. The prevalence of 

PTSD in NYC school 

children was 11% compared 

to the 2% observed in an 

appropriatecomparisonstudy 

(2), indicating PTSD in NYC 

students was 5% times Marylene CloItre 

that of rate obtained in 

the comparable population. The report also noted that 

only a minority of students had sought treatment either 

within the school system or from an outside mental 

health professional. While the proportion of children 

with PTSD who spoke to a school guidance counsel 

or school social worker was higher in Ground Zero 

schools, roughly two-thirds of children had not sought 

out or received any treatment. 

The obtained rate of disorders is likely to 

represent the proverbial " tip of the iceberg " There I 
are as yet unquantified subsnydromal symptoms that 

may negatively impact on functional status and quality 

of life. For example, panic attacks and symptoms of separation 

anxiety and agoraphobia that do not meet criteria for the 

disorder may still produce lateness or poor attendance at school, 

contributing further to the already high level of stress in affected 

families. Given this state of affairs, it is useful to consider what 

strategies might be implemented to enhance mental health in 

school children. There are only a handful of studies that have 

explored interventions with children and adolescents 

traumatized by large-scale disaster or single incident events (3-

7). In the studies that had a "no-intervention" comparison 

group, children who received services were better off than 

those who did not (3, 5,6). It is notable that all the studies were 

completed with youth who were symptomatic at least one year 

post trauma, with severity of symptoms typically close to that 

which would be observed for full-blown PTSD. The 

implementation of intervention at dates so many months 

following the large-scale community traumas is likely due to 

the tremendous practical and logistical difficulties involved in 

43 
NC-PTSD Clinical Quarterly 

such efforts. This inevitably circumscribes the conclusions that 

we can make. Nevertheless, the data indicate that youth who 

are symptomatic at a minimum of one-year post trauma are 

better off for having some form of intervention and are better 

off than those who do without. To our best knowledge, then, 

we can say that the first imperative of health providers - "to do 

no harm" - appears to have been established. Secondly, it appears 

that improvement is not simply die result of passage of time 

or the normal course of recovery, but is actively facilitated by 

treatment. Tills is true for both children (3-5,7) and adolescents (6). 

The risks involved in not intervening with youth who 

have been exposed to traumatic violence have recently been 

suggested in research that has reported myriad problems in 

traumatized youth by late adolescence and include increased 

rates of posttraumatic stress disorder, additional mental health 

disorders, interpersonal problems, overall behavior problen~s, 

academic failure and health problems (8). 

School based interventions (3, 6) have the advantage 

of providing psycho-education and outreach to a high 

proportion of affected youth. Organization of interventions 

in schools meets the twin needs of maximizing participation 

and monitoring of quality of implementation by school based 

mental health professionals. Furthermore, a school-based 

program may produce an aura of acceptability for mental health 

intervention and create a social context in which trauma related 

psychological symptoms are destigmatized. 

It remains unclear which particular treatment 

intervention should be adapted and implemented in the school 

system. However, a reasonable beginning is the proposal of a 

model and the minimum requirements for it. The largest and 

most rigorously evaluated intervention for children to date has 

been reported by Chemtob and colleagues among children two 

years following the Inild hurricane in Hawaii (4).The treatment 

represents an intervention model that is brief, theme-focused, 

and targeted for symptomatic children. The intervention was 

tested in a controlled trial of 250 children ages 8-12 (grades 2 

through 7)across 10 pubic schools. As such, it satisfies the highest 

standard of evaluation (evidence based) and is the only 

intervention for traumatized children following large-scale 

disaster for which this level of outcome evaluation has been 

obtained. In addition, it shares many features of other 

interventions for which there is some evidence of effectiveness 

(3-7) and thus represents a prototype of the key features of 

any effective treatment for traumatized children. This intervention 

may serve as a prototype model for our continuing efforts for 

the following reasons. 

First, the model is organized around children's most 

prevalent concerns and to a lesser extent their symptoms. 

Trauma creates specific disruptions and concerns across all ages 

(10). The central four disruptions are: 1) diminished sense of 

Volume 11 (3) 2002 

LESSONS LEARNED FROM 9/11 

safety and increased fear, 2) experience of loss and associated 

grief and anger, 3) diminished sense of the world/people as 

good and trustworthy, and 4) diminished sense competency 

and mastery (e.g., reduced school, social and home functioning). 

The treatment model is organized with each of these 

concerns as a theme of intervention with a certain number of 

sessions devoted to each theme. This is a very wise and 

developmentally informed approach to disaster-related 

treatment protocols that are expected to be implemented across 

a great number of children of different ages. Notably, the 

New York City Board of Education study found age-related 

differences in the prevalence of disorders. Children in the 4th 

and 5th grade had higher rates of the anxiety disorders such as 

agoraphobia and separation anxiety, while the adolescents 

showed significantly higher rates of depression and conduct 

disorder. These differences are interesting as they are consistent 

with and support theories concerning the developmental issues 

of growing autonomy and independence. They also point out 

the reality of changing symptoms profiles across different age 

groups. The organization by tliemes provides an overarching 

structure to guide mental health providers in implementing the 

treatment and heightens their sensitivity to the central issues that 

they will confront. Interventions related to specific symptom 

sets can be added on in modular fashion as relevant. 

The model uses two specific interventions shared by 

all trauma therapies: psycho-education and normalization of 

the psychological and functional consequences of trauma, and 

age-appropriate "en~otional processing" of core fears (via talk, 

expressive art or play). Notably, additional types of interventions 

which have been successful for youth exposed to other traumas 

(physical and sexual abuse) include stress management techniques, 

cognitive interventions and the inclusion of a parental treatment 

component, which might be helpful depending on the age and 

developmental needs of a particular set of children. (8). 

Importantly, the study demonstrated that school counselors 

learned and effectively administered the intervention, with 

appropriate supervision. It is important that any intervention 

model be able to be effectively implemented by the personnel 

in the schools. The use of school-based professionals such as 

school counselors serves an important long-term goal of 

intervention, which is maintenance of a trauma-focused 

knowledge base among those continuously working with youth 

across several years. It also enhances continuity in the professional 

knowledge base of school staff, providing competence and 

guidelines for appropriate action in die ongoing evolution of 

the consequences of events such as 9/11 and readiness for 

appropriate action for future events. Lastly, the intervention 

was shown to be effective in either a group or individual format, 

again providing a measure of flexibility across the differing 

needs and resources of variously affected schools and grades. 
NC-PTSD Clinical Quarterly 	 Volume 11 (3) 2002 

CLOITRE 

Our own experience with 7 of the Ground Zero schools adds to 

considerations for the development of such programs. The 

first is that it is likely that cogrdtive-behavioral modalities are 

preferable to open-ended nonspecific treatments. Active, 

focused, well-articulated, and time-limited interventions 

appeared to reduce the fear of the unknown for parents and 

children entering an intervention program. This is characteristic 

of cognitive-behavioral as compared to supportive therapies. 

Furthermore, evidence related to the treatment of traumatized 

children indicates the superiority of such treatments compared 

to nonspecific treatments for other forms of traumas (9). 

Special considerations and interventions should be given to 

adolescents. They are much more likely to express and attempt 

to modulate their fear and emotional distress through risk related 

behaviors such as anger, aggression, drinking and drug use. 

Interventions at the adolescent level should be tailored with 

these problems in mind. 

Last but not least, special considerations should be given 

to the teachers and mental health providers. Therapists and 

teachers are not immune to the effects of large-scale traumas 

such as 9/11 trauma in their own lives. Furthermore, those that 

assist traumatized children have an additional performance 

burden as they are called upon to provide support, comfort, 

knowledge and clinical services and incidentally act as role 

models for students and parents in the trauma recovery process. 

These multiple demands canlead to deterioration in effectiveness 

in role and personal life functioning (10). Teachers may be 

further burdened by a sense of inadequacy when confronted 

with newly emerging problematic behaviors in die classroom. 

Specific funding should be put aside to provide supportive, 

educational and therapeutic services for the teachers and other 

professionals who are daily exposed to the students. Such 

services should include expanded education concerning such 

issues as behavior management and de-escalation of emotional 

crises in the classroom. In addition, time-limited and evidence 

based interventions should be made available to address the 

therapeutic needs of these professionals. 

The current available controlled studies of school based 

interventions as well as the emerging consensus by expert 

clinicians give good reason to be optimistic about the feasibility 

and potential effectiveness of school based programs. The 

remaining challenges are sufficient funding and continued 

cooperative spirit among schools, parents and mental health 

providers. 

We need yet to determine whether this community 

trauma is best understood generically as a disaster, similar in its 

effects to natural disasters such as hurricanes and floods, or 

whether the effects will better understood as an event of large 

scale violence perpetrated by human design. Careful evaluation 

of symptom sets over the next months and years will be needed 

to make this determination and help guide treatment 

development for children who develop chronic, long-term 

problems. 

References 

1. 	 Initial Report to the New York City Board of Education 

(May 2002). Effects of the World Trade Center Attack on 

NYC Public School Students. Prepared by Applied 

Research and Consulting LLC, Columbia University 

Mailman School of Public Health, and the New York 

State Psychiatric Institute. 

2. 	 Schwab-Stone, M.E., Shaffer, D., Dulcan, M.K., Jensen, P.S. 

et al., (1996). The NIMH Diagnostic Interview Schedule 

for Children Version 2.3 (DISC 2.3): Description, 

acceptability, prevalence rates and performance in the 

MECA Study. Journal of die American Academy of Child 

and Adolescent Psvchiat~y, 3,7. 

3. 	Chemtob, C.M., Nakashima, J.P., Roger, H.S. (2002). 

Psychosocial intervention of post disaster trauma 

symptoms in elementary school children. Archives of 

Pediatric and Adolescent Medicine, m,21 1-216. 

4. Chemtob, C.M., Nakashima, J., Carlso, J.G. (2002). Brief 

treatment for elementary school children with disaster 

relatcd posttrautnatic stress disorder: A field study.- 

of Clinical Psvcholog~, 58,579-1 12. 

5. Galante, R. & Foa, E. (1986). An epidemiological study of 

psychic trauma and treatment effectiveness for children 

after a natural disaster. journal of the American Academy 

of Child and Adolescent Psychiatry, 25,357-363. 

6. Goenjian, A.K., Karayan, I., Pynoos, R.S., Minassian, D., 

Najarian, L.M., Steinberg, A.M., Fairbanks, L.A. (1997). 

Outcome of psychotherapy among early adolescents after 

trautna. American lournal of Psvchiatry, m,536-542. 

7. March, J.S., Amaya-Jackson, L., Murray, M.C., Scliulte, A. 

(1998). Cognitive-behavioral psychotherapy for children 

and adolescents with posttraumatic stress disorder after a 

single-incident stressor. journal of die American Academy 

of Child and Adolescent Psychiatry, 37,585-593. 
NC-PTSD Clinical Quarterly 	 Volume 11 (3) 2002 

LESSONS LEARNED FROM 9/11 WOMEN ANDTRAUMA: ACLINICAL FORUM 

CONTINUED FROM PAGE 41 

References 

8. Gianconia, P.M., Reinherz, H, Silverman, A.B., Pakiz, B., 1- Roodman, & Glum, G.A. (2001). Revictimization rates 

Frost, A.I<., Cohen, E. (1995). Traumas and posttraumatic and method variance: A meta-analysis. Clinical Psvchology 

Review, 21, 183-204. 

stress disorder in a community population of older 

adolescents.Journal of the Amrican 2. Merrill, L.L. Newell, C.E., Thomsen, CJ,, Gold, S.R., Miller, 

and Adolescent Psychiatry, 34, 1369-1380. J.S., Koss, M.P., & Rossworlz, S.G. (1999). Childhood abuse 

and sexual revictimization in a female Navy recruit sample. 

9. Cohen, J.A., Mannarino, A.P., Berliner, L., Deblinger, E. Journal of Traumatic Stress, .12, 211-225. 

(2000). Trauma-focused cognitive behavioral therapy for 3. Coyle, B.S. Wolan, D.L.,&Van Horn, AS. (1996). The prevachiidren and adolescents: an empirical update. Iournal of lence of physical and sexual abuse in women veterans seekInterpersonal Violence, 15,1202-1 223. ing care at a veterans affairs medical center. Military Medi-

&, 161, 588-593. 

10.Janoff-Bulmann, R. (1992). Shattered Assumptions: Towards 

4. Foa, E.B., Keane, T.M., & Friedman, MJ. (Eds). (2000). EÂ

a New Psvchology of Trauma. New York: Macmilian. fective treatments for PTSD. New York: Guilford Press. 

11. Catheral, D.R. (1995). Preventing Institutional Secondary 5. DowdesweUJ (1986). Womenon race. NewYork: Thorsons 

Stress Disorder. In (Ed.) C.R. Figley, Compassion Fatigue: Publishing. 

Cooing with secondary traumatic stress disorder in those 

6. Searles, I? & Berger, R.. (1987). The feminist self defense who treat the traumatized, (pp. 232-247). New York: 

movement: A case study. Gender and Society, 61,61-84. 

Brunner/Mazel. 

7. 	 Giggans, P.0. (1999). Self-defense. In CALCASA (Eds), 

Suocort for survivors: Training for sexual assault sun- 

-(pp. 395-404). Sacramento, CA: California Coalition 

Against Sexual Assault. 

Marylene Cloitre, Ph.D. is The Cathy and Stephen 8. Koss, M.l? (1989). Hidden rape: Sexual aggression and vicGraham Professor of Psychiatry and the Director timization in a national sample of students in higher educaof The Institute for the Study of Trauma Recover)' tion. In,M Pirog-Good and J., Steds (Eds). Violence in dating 

at the NYU Child Study Center. relationships: Emerehe sod issues. New York Praeger. 

I 	 I 

9. 	 Levine-MacCombie, J., & I<oss, M.P. (1986). Acquaintance 

rape: Effective avoidance strategies. psycho lo^^^ of Women 

Outed; 10, 311-320. 

10. Peri, C. (March, 1991). Below the belt. Newsletter of the 

National Women's Martial Arts Federation (pp.6-14). 

11. Weidauf, J.C., Cervone, D., Smith, RE.,& Wright, P.M. (2001). 

Assessing generalization in perceived self-efficacy: 

Multidomain and global assessment of the effects of selfdefense training from women. Personality and Social Psvcholoev Bulletin, 27, 1683-1691. 

12. Naugle, A.E., Bell, K.M. & Polusny, M.A. fin press). Clinical 

considerations for treating sexually revictimized women. 

National Center for PTSD Clinical Quarterly. 
- -- - - - - - 

NATIONAL CENTER FOR PTSD 


EDUCATION, TRAINING, & SUPPORT SERVICES 


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 

Sramm, 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 Medo 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 PTSD-related concerns. Telephone (650) 493-5000 ext 22977. 

National Center for PTSD Web Page 

The NC-PTSD Home Page provides a description of activities of the National Center for PTSD and other trauma 

related information. The world wide web address is: http'://mnv.n@tsdotg 

PILOTS Database 

PILOTS, the only electronic index focused exclusively on the world's 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. http://ivwiy.n@tsd.o~/PILOTS.html 

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 and consultation in disaster mental health services. Training topics include key 

concepts, interfacing with other agencies, pre-, within-, and post-disaster risk factors, psychological first aid, 

screening for adverse mental health outcomes, early intervention, guidelines for working in large group settings, 

support for bereavement, working "with special populations, disaster worker stress, referral, self-care before, 

during, and after an assignment, and other related topics. Telephone (650) 493-5000 ext. 22494 or email: 

nct>tsd@bmcewÃ§ng.ne 

Conferences and Training Events 

The Medo 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 Clinical Quarterly Volume 11 (3) 2002 

NATIONAL CENTER FOR PTSD 


CLINICAL TRAINING PROGRAM 


The Education and Clinical Laboratory 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 30 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 

knowledge 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 consultation 

* Clinical observation of group treatment * Group discussions facilitated by staff 

Specific training topics 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 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, on the second or third week of the month. 

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: 

Josef.Ruzek@rned.va.gov 

or telephone PTS 700-463-2673; commercial number 650-493-5000, ext. 22673.