Psychotherapy begins with diagnosis, a process of identifying or determining the nature and cause of a disease or injury through a critical analysis of a patient's history, an examination, and a review of empirical data. One of the most vexing issues to be encountered in psychology is the identification-for clinical and forensic purposes-of Posttraumatic Stress Disorder (PTSD). The Diagnostic and Statistical Manual of Mental Disorders (1994) lists PTSD (309.81) under anxiety disorders, stating that it may result from direct or indirect exposure to trauma. Its essential features include intrusive and avoidance symptoms, and symptoms of hyperarousal, for greater than 1 month and causing clinically significant distress or impairment in important life areas. Indirect traumata may include observing the serious injury or death of another person through violence, accident, war, or disaster or the chance encountering of a corpse or body parts. Although Adjustment Disorder and PTSD both require a psychosocial stressor, PTSD is identified by an extreme stressor and specific symptoms, while Adjustment Disorder may be triggered by a stressor of any severity and can involve a wide range of symptoms.
Forensic experts can assess emotional damage--including PTSD--claimed by the patient or family within the context of life histories, including preexisting mental conditions and prior experiences that make a patient vulnerable to trauma. They can also report on the probability of faking, malingering, or exaggerating symptoms, assessments of this type having value in establishing treatment plans/goals and in helping a jury evaluate the patient's credibility and damage.
Consequently, to appropriately and comprehensively assess PTSD we must examine the nature and degree of trauma, the trauma history, the pretraumatic state (including chronic strains, negative life experiences in the year before the trauma, health problems over the preceding ten years, recent life events, and personality traits and disorders), the immediate social surround, dynamics of the traumatic episode, the posttraumatic state, social supports, and an altered worldview and belief systems.
Although an ever-growing corpus of literature and research information on PTSD is extant, the goal of this article is to provide a brief, introductory overview of the syndrome, its antecedents and precipitants, components of the experience and treatment implications. Additional writings will examine each aspect in greater depth.
At least 7 factors have been found to be associated with PTSD as antecedents, precipitants, or collateral events and/or features of PTSD.
Pre-existing traumas. These have a cumulative or sensitizing effect upon the ease of acquisition of later trauma (Blanchard & Hickling, 1997; Brewin, Dalgleish & Joseph, 1996; McKenzie & Wright, 1996; Resnick, Yehuda & Foy,1995).
The pretraumatic state, the immediate social environment, the nature of the trauma, the dynamics of the traumatic episode, and the nature of the posttraumatic state which contribute to the stability of the disorder (Woolston, 1988).
Recent life events, chronic strains, and social supports (Ullman & Siegel, 1994). Risk of increased posttraumatic stress (PTS) symptoms following a traumatic event was associated with other life events, sexual assault, and household strain. The level of PTS varied according to the trauma after adjusting for demographics. Women and younger adults reported more PTS than other subjects.
Negative life events during the year before the trauma, health problems during the previous ten years, and a personality trait characterized by high emotional reactivity (Tjemsland, Soreide, & Malt, 1998).
Personality disorders. These may occur in 5 to 15 percent of the population. Patients with personality disorder have not only a maladaptive response to stress but elicit dysfunctional responses by a pervasive pattern of interpersonal stress (Adams, 1997).
Worldview: After trauma, one's worldview (in German, Weltanschauung) may alter. This is the general perspective used to perceive and interpret reality, the existential beliefs supporting one's existence. Perceptions of vulnerability are heightened and self-view are significantly diminished for trauma victims, with similar results across different types of trauma (Gluhoski & Wortman, 1996).
The degree of trauma: There is a correlation between the severity of PTSD and the presence of other disorders, including depression, substance abuse disorders, adjustment disorders, psychosomatic disorders, and antisocial behavior (Rundell, Ursano, Holloway, & Silberman, 1989).
Blanchard, Kolb, Pallmeyer, and Gerardi (1982) found that psychophysiological comparisons between male Vietnam veterans suffering from PTSD and nonveteran controls resulted in the two groups responding differently to combat reminders in heart rate (HR), systolic blood pressure, and forehead electromyography (EMG). HR responses led to correct classification of 95.5 percent of the combined sample. Similarly, in a replication study of physiological measures of injured motor vehicle accident victims and non-injured controls, Blanchard, Hickling, Buckley, Taylor, Vollmer, and Loos (1996) found HR useful in distinguishing MVA victims with PTSD from those with subsyndromal PTSD and non-PTSD. The initial psychophysiological assessment results predicted 1-year follow-up clinical status for the majority of individuals who initially met criteria for PTSD.
Wickramasekera (1998) defines 3 risk factors associated with PTSD symptom intensity. These are high hypnotic ability (high dissociation), low hypnotic ability (low dissociation), and a high Marlowe-Crowne score (Crowne & Marlowe, 1960). The latter measures culturally acceptable statements that are probably untrue of most people and undesirable statements. These measures may produce incongruent responses between psychologi cal measures (e.g. no perception or memory of negative emotions) and physiological (e.g. sympathetic activation, high skin conductance, high heart rate, high blood pres sure) measures of threat perception. These risk factors reduce or block negative emotions from conscious awareness but not from behavior (e.g. violence, avoidance, substance abuse) or physiology (e.g. mi graines, autonomic nervous system dysregulation, musculoskeletal pain).
From the above, the usefulness of psychophysiological measures may be adduced as a valuable supplement to PTSD assessment.
Dissociation is described as "a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The disturbance may be sudden or gradual, transient or chronic" (DSM IV, 1994). Posttraumatic Stress Disorder (PTSD) may be conceptualized as part of a dissociative spectrum in which recall/re-experiencing of the trauma (flashbacks) alternates with numbing (detachment or dissociation), and avoidance (Turkus, 1992; also see Briere, Evan, Runtz, & Wall, 1988; Carlson & Rosser-Hogan, 1991; Goodwin & Reynolds, 1987; Jaschke & Spiegel, 1992; Kuch & Cox, 1992; Mellman, Randolph, Brawman-Mintzer, Flores, & Milanes,1992; Roszell, McFall, & Malas, 1991; Shalev, Schreiber, & Galai, 1993; Southwick, Yehuda, & Giller, 1993).
As Wickramasekera (1998) addressed hypnotizability, Spiegel, Hunt, and Dondershine (1988) examined this trait in veterans with PTSD contrasted with a normal control group and four patient samples. The results demonstrated that PTSD patients show significantly higher hypnotizability scores than patients with schizophrenia, major depression, bipolar disorder-depressed, dysthymic disorder, generalized anxiety disorder and the controls. This supports the hypothesis that dissociation effects may are used as defenses during and after traumatic experiences.
Bremner and Brett (1997) examined dissociation in premilitary, combat-related and postmilitary traumas and the presence of long-term psychopathology in Vietnam combat veterans with and without PTSD. Most interesting was the finding that PTSD patients reported higher levels of dissociative states at the time of combat-related traumatic events than non-PTSD patients. These higher levels of dissociative states persisted in PTSD patients as higher levels of dissociation in response to postmilitary traumatic events. The dissociative responses to combat trauma were linked with higher, long-term dissociative symptoms as measured by the Dissociative Experience Scale and an increased number of "flashbacks" since the time of the war. The findings are congruent with earlier concepts that traumatic dissociation may be a sign of long-term psychopathology.
Contrary to the symptom-specific expectations of insurance reviewers, current research demands flexibility in the diagnoses and treatment of PTSD. In some instances (see Foa, Hearst-Ikeda, & Perry, 1995), brief cognitive-behavioral program undertaken shortly after assault reduce the reexperiencing of severe arousal symptoms as well as depression. However, a history of physical abuse in childhood has been strongly correlated with dissociative symptoms later in life as well as combat experiences in veterans (Spiegel, &. Cardena, 1990). As dissociative symptoms during and soon after traumatic experience predict later PTSD, brief, symptom-focused treatment may not always be applicable.
Hypnotic procedures may be helpful because the population has been shown to be highly hypnotizable. Hypnosis provides regulated access to painful memories that may otherwise be blocked from awareness. In treating PTSD victims, dissociated traumatic memories are connected with a positive restructuring of involved memories, a cognitive reorientation. Accordingly, patients are helped to confront and manage traumatic experiences by inserting them into a new context meaning or "worldview." Feelings of helplessness are endorsed while experiences are interlaced with restructured memories, emphasizing positive efforts at self-protection, affection with the living and those who may have died, or the capacity to control events and the environment at other times.
Although medication use shows a modest, clinically meaningful effect on PTSD, in their literature review on the effectiveness of PTSD treatments, Solomon, Gerrity, and Muff (1992) found more robust effects for behavioral techniques involving direct therapeutic exposure in reducing PTSD intrusive symptoms. There is a caveat, however, in that complications were reported from the use of these techniques in patients with collateral psychiatric disorders. Cognitive therapy, psychodynamic therapy, and hypnosis may also hold promise, but further research is needed.
Psychodynamic psychotherapy focuses on helping the patient examine their reactions to the physical or emotional personal violations of the traumatic event(s). The goal is to increase awareness of intrapersonal conflicts and their resolution. The patient is guided towards developing increased self-esteem, self-control, and a regenerated sense of personal integrity and self-confidence.
Group therapy may help PTSD patients develop a reference group and a sense of community, reacquiring the capacity to relate to others in a controlled, health-inducing manner and setting.
Most PTSD treatment is outpatient. When symptoms make it impossible to function or lead to other symptoms (e.g., alcohol or drug problems) inpatient treatment may become necessary.
PTSD is a diagnostically complex phenomenon requiring a multidimensional evaluation including clinical interviewing, background history, adequate testing and test interpretation, and psychophysiological assessment. These are imperative for diagnosis, treatment and competent testimony (Levit, 1986). In my practice, interviewing, psychometric testing, malingering/exaggerating measures, and physiological responses to positive, negative and neutral stimuli are blended, similar to Scrignar's (1988) biopsychosocial model of PTSD, to include Environment, Encephalic Events, and Endogenous Events.
Effective psychological and pharmacological treatments are available for PTSD. Medications may be used as a complement to psychotherapy to help sleeplessness and hyperarousal. Psychotherapy restores the patient's necessary sense of control while decreasing the impact of past events over present experience. The sooner a patient is diagnosed and treated, the more likely s/he is to recover from trauma. A sense of safety and control in the patients' lives must be re-established to help them feel effective and secure enough to embrace the feared reality of the events that transpired.
Social and familial support may be critical. Time must be permitted for grief and mourning, while communicating about events and receiving support for feelings of guilt, anger, self-blame, and depression. A treatment plan must be developed with the patient to help establish what is needed to restore a sense of confidence, control and predictability to life.
Forensic proof of the existence of PTSD requires that many of the needs and conditions cited here are met. Even when presented with solid, empirical evidence of PTSD, adversaries will often attempt to deny its existence or, as I have seen lately, attempt to transport responsibility for present distress onto earlier events or injuries. As forensic specialists, our primary, professional responsibilities are to the patient. However, in serving the patient, we may also meet the needs of the legal system through responsible, detailed, and thorough documentation of diagnosis and treatment supported by research.