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Psychological and Physiological Trauma Research
Seize Your Journeys
_______________________ Traumatic stress is found in many competent, healthy, strong, good people. No one can completely protect themselves from traumatic experiences. Many people have long-lasting problems following exposure to trauma. Up to 8% of persons will have PTSD at some time in their lives. People who react to traumas are not going crazy. What is happening to them is part of a set of common symptoms and problems that are connected with being in a traumatic situation, and thus, is a normal reaction to abnormal events and experiences. Having symptoms after a traumatic event is NOT a sign of personal weakness. Given exposure to a trauma that is bad enough, probably all people would develop PTSD. By understanding trauma symptoms better, a person can become less fearful of them and better able to manage them. By recognizing the effects of trauma and knowing more about symptoms, a person will be better able to decide about getting treatment. _______________________
FUNCTIONAL NEUROANATOMY In order to best understand this atlas it is important to have a sense of the functional neuroanatomy of the brain. Over the next several pages there is a brief summary of the 5 major brain systems that relate to behavior, along with the general location seen on SPECT of these areas.
The Deep Limbic System
Functions
Problems
The Basal Ganglia System
Functions
Problems
The Prefrontal Cortex
Functions
Problems
The Cingulate Gyrus
Problems
The Temporal Lobes
Functions
Problems
Non-dominant Side (usually the right)
Secure Attachments as a Defense Against Trauma “All people mature and thrive in a social context that has profound effects on how they cope with life’s stresses. Particularly early in life, the social context plays a critical role in fuffering an individual against stressful situations, and in building the psychological and biological capacities to deal with further stresses. The primary function of parents can be thought of as helping children modulate their arousal by attuned and well-timed provision of playing, feeding, comforting, touching, looking, cleaning, and resting—in short, by teaching them skills that will gradually help them modulate their own arousal. Secure attachment bonds serve as primary defenses against trauma-induced psychopathology in both children and adults (Finkelhor & Browne, 1984). In children who have been exposed to severe stressors, the quality of the parental bond is probably the single most important determinant of long-term damage (McFarlane, 1988).” van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds. 1996. Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York and London: Guilford Press. .p. 185 _______________________
Sleep Disorders
“The sleep disorders are organized into four major sections according to presumed etiology. Primary Sleep Disorders are those in which none of the etiologies listed below (i.e., another mental disorder, a general medical condition, or a substance) is responsible. Primary Sleep Disorders are presumed to arise from endogenous abnormalities in sleep-wake generating or timing mechanisms, often complicated by conditioning factors. Primary Sleep Disorders in turn are divided into Dyssomnias (characterized by abnormalities in the amount, quality, or timing of sleep) and Parasomnias (characterized by abnormal behavioral or physiological events occurring in association with sleep, specific sleep stages, or sleep-awake transitions). Sleep Disorder Related to Another Mental Disorder involves a prominent complaint of sleep disturbance that results from a diagnosable mental disorder (often a Mood Disorder or Anxiety Disorder) but that is sufficiently severe to warrant independent clinical attention. Presumably, the pathophysiological mechanisms responsible for the mental disorder also affect sleep-awake regulation. Sleep Disorder Due to a General Medical Condition involves a prominent complaint of sleep disturbance that results from the direct physiological effects of a general medical condition on the sleep-wake system. Substance-Induced Sleep Disorder involves prominent complaints of sleep disturbance that result from the concurrent use, or recent discontinuation of use, of a substance (including medications). That systematic assessment in individuals who present with prominent complaints of sleep disturbance includes an evaluation of the specific type of sleep complaint and a consideration of concurrent mental disorders, general medical conditions, and substance (including medication) use that may be responsible for the sleep disturbance. Five distinct sleep stages can be measured by polysomnography: rapid eye movement (REM) sleep and four stages of non-rapid eye movement (NREM) sleep (stages 1, 2, 3, and 4). Stage 1 NREM sleep is a transition from wakefulness to sleep and occupies about 5% of time spent asleep in healthy adults. Stage 2 NREM sleep, which is characterized by specific EEG waveforms (sleep spindles and K complexes), occupies about 50% of time spent asleep. Stages 3 and 4 NREM sleep (also known collectively as slow-wave sleep) are the deepest levels of sleep and occupy about 10%-20% of sleep time. REM sleep, during which the majority of typical storylike dreams occur, occupies about 20%-25% of total sleep. These sleep stages have a characteristic temporal organization across the night. NREM stages 3 and 4 tend to occur in the first one-third to one-half of the night and increase in duration in response to sleep deprivation. REM sleep occurs cyclically throughout the night, alternating with NREM sleep about every 80-100 minutes. REM sleep periods increase in duration toward the morning. Human sleep also varies characteristically across the life span. After relative stability with large amounts of slow-wave sleep in childhood and early adolescence, sleep continuity and depth deteriorate across the adult age range. This deterioration is reflected by increased wakefulness and stage 1 sleep and decreased stages 3 and 4 sleep. Because of this, age must be considered in the diagnosis of a Sleep Disorder in any individual. Polysomnography is the monitoring of multiple electrophysiological parameters during sleep and generally includes measurement of EEG activity, electroculographic activity, and electromyographic activity. Additional polysomnographic measures may include oral or nasal airflow, respiratory effort, chest and abdominal wall movement, oxyhemoglobin saturation, or exhaled carbon dioxide concentration; these measures are used to monitor respiration during sleep and to detect the presence and severity of sleep apnea. Measurement of peripheral electromyographic activity may be used to detect abnormal movements during sleep. Most polysomnographic studies are conducted during the person’s usual sleeping hours—that is, at night. However, daytime polysomnographic studies also are used to quantify daytime sleepiness. The most common daytime procedure is the Multiple Sleep Latency Test (MSLT), in which the individual is instructed to lie down in a dark room and not resist falling asleep; this protocol is repeated fives times during the day. Sleep latency (the amount of time required to fall asleep) is measured on each trial and is used as an index of physiological sleepiness. The converse of the MSLT is also used: In the Repeated Test of Sustained Wakefulness (RTSW), the individual is placed in a quiet, dimly lit room and instructed to remain awake; this protocol is repeated several times during the day. Again, sleep latency is measured, but is it used here as an index of the individual’s ability to maintain wakefulness. Standard terminology for polysomnographic measures is used throughout the test in this section. Sleep continuity refers to the overall balance of sleep and wakefulness during a night of sleep. “Better” sleep continuity indicates consolidated sleep and wakefulness; “worse” sleep continuity indicates disrupted sleep with more wakefulness. Specific sleep continuity measures include sleep latency—the amount of time required to fall asleep (expressed in minutes); intermittent wakefulness—the amount of awake time after initial sleep onset (expressed in minutes); and sleep efficiency—the ratio of actual time spent asleep to time spent in bed (expressed as a percentage, with higher numbers indicating better sleep continuity). Sleep architecture refers to the amount and distribution of specific sleep stages. Sleep architecture measures include absolute amount of REM sleep and each NREM sleep stage (in minutes), relative amount of REM seep and NREM sleep stages (expressed as a percentage of total sleep time), and latency between sleep onset and the first REM period (REM latency). The text for each of the Sleep Disorders contains a section describing its relationship to corresponding disorders in The International Classification of Sleep Disorders: (ICSD) diagnostic and Coding Manual, published in 1990 by the American Sleep Disorders Association. _________________
Substance Dependence “Features The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior. A diagnosis of Substance Dependence can be applied to every class of substances except caffeine. The symptoms of Dependence are similar across the various categories of substances, but for certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for Hallucinogenic Dependence). Although not specifically listed as a criterion item, “craving” (a strong subjective drive to use the substance) is likely to be experienced by most (if not all) individuals with Substance Dependence. Dependence is defined as a cluster of three or more of the symptoms listed below occurring at any time in the same 12-month-period. Tolerance (Criterion 1) is the need for greatly increased amounts of the substance to achieve intoxication (or the desired effect) or a markedly diminished effect with continued use of the same amount of the substance. The degree to which tolerance develops varies greatly across substances. Furthermore, for a specific drug, varied degrees of tolerance may develop for its different central nervous system effects. For example, for opioids, tolerance to respiratory depression and tolerance to analgesia develop at different rates. Individuals with heavy use of opioids and stimulants can develop substantial (e.g., 10-f0ld) levels of tolerance, often to a dosage that would be lethal to a nonuser. Alcohol tolerance can also be pronounced, but is usually less extreme than for amphetamine. Many individuals who smoke cigarettes consume more than 20 cigarettes a day, an amount that would have produced symptoms of toxicity when they first started smoking. Individuals with heavy use of cannabis or phencyclidine (PCP) are generally not aware of having developed tolerance (although it has been demonstrated in animal studies and in some individuals). Tolerance may be difficult to determine by history alone when the substance used is illegal and perhaps mixed with various diluents or with other substances. In such situations, laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely). Tolerance must also be distinguished from individual variability in the initial sensitivity to the effects of particular substances. For example, some first-time drinkers show very little evidence of intoxication with three or four drink, whereas others of similar weight and drinking histories had slurred speech and incoordination. Withdrawal (Criterion 2a) is a maladaptive behavioral change, with physiological and cognitive concomitants, that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing unpleasant withdrawal symptoms, the persons is likely to take the substance to relieve or to avoid those symptoms (Criterion 2b), typically using the substance throughout the day beginning soon after awakening. Withdrawal symptoms, which are generally the opposite of the acute effects of the substance, vary greatly across the calluses of substances, and separate criteria sets for Withdrawal are provided for most of the classes. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms are often present, but may be less apparent, with stimulants such as amphetamines and cocaine, as well as with nicotine and cannabis. No significant withdrawal is seen even after repeated use of hallucinogens. Withdrawal from phencyclidine and related substances has not yet been described in humans (although it has been demonstrated in animals). Neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence. However, for most classes of substances, a past history of tolerance or withdrawals is associated with a more severe clinical course (i.e., an earlier onset of Dependence, higher levels of substance intake, and a greater number of substance-related problems). Some individuals (e.g., those with Cannabis Dependence) show a pattern of compulsive use without obvious signs of tolerance or withdrawal. Conversely, some general medical and postsurgical patients without Opioid Dependence may develop a tolerance to prescribed opioids and experience withdrawal symptoms without showing any signs of compulsive use. The specifiers With Physiological Dependence and Without Physiological Dependence are provided to indicate the presence or absence of tolerance or withdrawal. The following items describe the pattern of compulsive substance use that is characteristic of Dependence. The individual may take the substance in larger amounts or over a longer period than was originally intended (e.g., continuing to drink until severely intoxicated despite having set a limit of only one drink) (Criterion 3). The individual may express a persistent desire to cut down or regulate substance use. Often, there have been many unsuccessful efforts to decrease or discontinue use (Criterion 4). The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 5). In some instances of Substance Dependence, virtually all of the person’s daily activities revolve around the substance. Important social, occupational, ore recreational activities may be given up or reduced because of substance use (Criterion 6). The individual may withdraw from family activities and hobbies in order to use the substance in private or to spend more time with substance-using friends. Despite recognizing the contributing role of the substance to a psychological or physical problem (e.g., sever depressive symptoms or damage to organ systems), the person continues to use the substance (Criterion 7). The key issue in evaluating this criterion is not eh existence of the problem, but rather the individual’s failure to abstain from using the substance despite having evidence of the difficulty it is causing.
Specifiers Tolerance and withdrawal may be associated with a higher risk for immediate general medical problems and a higher relapse rate. Specifiers are provided to note their presence or absence: With Physiological Dependence. This specifier should be used when Substance Dependence is accompanied by evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). Without Physiological Dependence. This specifier should be used when there is no evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). In these individuals, Substance Dependence is characterized by a pattern of compulsive use (at least three items from Criteria 3-7).”
Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. P. 193-195.
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PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com __________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373
Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association.
________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373 Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. ________________ DID-PTSD-EMDR Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com
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NeuroBiology of Trauma
Affect Regulation and Post Traumatic Stress Disorder
Title: Ueberlebende von folter. Eine studie zu komplexen postraumatischen belastungsstoerungen./ Survivors of torture: A study of complex posttraumatic stress disorders. Author(s)/Editor(s): Teegen, Frauke; Vogt, Silke Author Affiliation: U Hamburg, Psychologisches Inst III, Hamburg, Germany Paper Number: 20020807 Source/Citation: Verhaltenstherapie & Verhaltensmedizin; Vol 23(1) 2002, Germany: Pabst Science Publishers; 2002, 91-106 Abstract/Review/Citation: The objective of this study was to question survivors of torture about the context and kind of the sustained torture and to administer a screening of lasting physical sequelae and symptoms of PTSD. Assuming that the experience of torture leads to very comprehensive trauma related syndromes, the construct of complex PTSD was additionally included. As item version was constructed on the basis of the Structured Interview of Disorders for Extreme Stress, which captures changes in affect regulation, self-perception, relationship capability, systems of meaning as well as somatic disorders. 33 survivors participated (male and female; mean age 41 yrs old). When experiencing torture for the first time, 21% were younger than 16 yrs old. 83% sustained lasting physical damage. PTSD was diagnosed in 94%. In addition to the syndrome of PTSD, two thirds exhibited the entire syndrome of a complex PTSD. ========================================
Title: Komplexe Posttraumatische Belastungsstoerung: Eine Untersuchung des diagnostischen Konstruktes am Beispiel misshandelter Frauen./ Complex posttraumatic stress disorders: An investigation of the diagnostic construct in a sample of abused women. Author(s)/Editor(s): Teegen, Frauke; Schriefer, Johanna Author Affiliation: U Hamburg, Psychologisches Inst III, Hamburg, Germany Paper Number: 20020807 Source/Citation: Zeitschrift fuer Klinische Psychologie, Psychiatrie und Psychotherapie; Vol 50(2) 2002, Germany: Verlag Ferdinand Schoningh; 2002, 219-233 Abstract/Review/Citation: In the context of an investigation on the sequelae of domestic violence, the diagnostic construct of "complex posttraumatic stress disorder," which captures changes in affect regulation, consciousness, self experience, relationship capability, systems of meaning, and somatization disorders, was assessed. 71 women, who had lived in an abusive relationship for 11 years on average, participated in the study. A posttraumatic stress disorder (PTSD; PCL-C according to DSM-IV) was found in 58%, and the syndrome of complex PTSD additionally in 27%. The analysis of correlational relationships revealed that syndrome patterns of a complex PTSD were developed primarily in combination with intrusions, arousal and avoidance symptoms and that they may be an indicator for the severeness of a PTSD after the prolonged experience of violence. Correlations with the SCL-90-R provided support for the validity of the diagnostic construct. ========================================
Title: Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Author(s)/Editor(s): Cloitre, Marylene; Koenen, Karestan C.; Cohen, Lisa R.; Han, Hyemee Author Affiliation: Columbia U, Dept of Public Health, New York, NY, US St. Luke's-Roosevelt Hosp, Dept of Psychiatry, New York, NY, US Weill Medical Coll of Cornell U, Dept of Psychiatry, New York, NY, US Source/Citation: Journal of Consulting & Clinical Psychology; Vol 70(5) Oct 2002, US: American Psychological Assn; 2002, 1067-1074 Abstract/Review/Citation: Fifty-eight women with posttraumatic stress disorder (PTSD) related to childhood abuse were randomly assigned to a 2-phase cognitive-behavioral treatment or a minimal attention wait list. Phase 1 of treatment included 8 weekly sessions of skills training in affect and interpersonal regulation; Phase 2 included 8 sessions of modified prolonged exposure. Compared with those on wait list, participants in active treatment showed significant improvement in affect regulation problems, interpersonal skills deficits, and PTSD symptoms. Gains were maintained at 3- and 9-month follow-up. Phase 1 therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success in reducing PTSD, suggesting the value of establishing a strong therapeutic relationship and emotion regulation skills before exposure work among chronic PTSD populations. ========================================
Title: Affect management in group therapy for women with posttraumatic stress disorder and histories of childhood sexual abuse. Author(s)/Editor(s): Wolfsdorf, Barbara A.; Zlotnick, Caron Source/Citation: Journal of Clinical Psychology: Special Issue: Treating emotion regulation problems in psychotherapy.; Vol 57(2) Feb 2001, US: John Wiley & Sons Inc; 2001, 169-181 Abstract/Review/Citation: Affect dysregulation is pervasive among women with histories of childhood sexual abuse. It is an important aspect of the clinical presentation of posttraumatic stress disorder (PTSD), a disorder that frequently characterizes survivors of childhood abuse. Based on distinctions between approach and avoidance orientations to coping, there is controversy regarding whether initial treatment for trauma survivors should employ an exposure-based approach to increase affect or an affect-management approach to reduce it. In this article, the authors review theoretical and empirical literature regarding affect dysregulation and its relations with childhood sexual abuse and PTSD. A new affect-management group for adult survivors of childhood sexual abuse is described that is based on a stage approach to the treatment of trauma. This group emphasizes skill acquisition, symptom reduction, and patient stabilization. Affect-management strategies such as mindfulness, crisis planning, and challenging distorted thinking are presented to patients. Preliminary research findings support the use of this treatment. ========================================
Title: Treating low-income and African American women with posttraumatic stress disorder: A case series. Author(s)/Editor(s): Feske, Ulrike Source/Citation: Behavior Therapy; Vol 32(3) Sum 2001, US: Assn for Advancement of Behavior Therapy; 2001, 585-601 Abstract/Review/Citation: The present uncontrolled case series was designed to examine the feasibility of prolonged exposure (PE) for posttraumatic stress disorder (PTSD) with low-income and African-American women. Five of 10 eligible women completed PE and showed significant improvements in symptoms of PTSD, general anxiety, and depression. Clinical observations suggest that the addition of interventions aimed at improving interpersonal problems might lead to a more complete recovery in this population of women with complex trauma and psychiatric histories and that a priming intervention focused on teaching affect-regulation skills might enhance the effectiveness of PE. The removal of structural barriers (e.g., lack of transportation and child care) appears to be necessary in order to boost the benefits of traditional treatment interventions in disadvantaged women. ========================================
Title: Cognitive-behavioral processes in managing the stress and anxiety of medical illness. Author(s)/Editor(s): Newton, Tamara L.; Doron, Susan E. Source/Citation: The management of stress and anxiety in medical disorders., Needham Heights, MA, US: Allyn & Bacon, Inc; 2000, (xiv, 418), 84-99 Source editor(s): Mostofsky, David I. (Ed) Abstract/Review/Citation: This chapter focuses on cognitive-behavioral interventions used to treat and manage emotional distress associated with medical conditions. The occurrence of a medical illness represents a major life event that may severely tax one's coping abilities and culminate in a complex biopsychosocial response. Cognition is central to this response, from attending to and appraising symptoms, to generating coping behaviors and forming internal illness representations comprising symptom experiences, emotion, and meaning. Accordingly, cognitive-behavioral interventions have been evaluated with regard to their ability to ameliorate emotional distress associated with a range of medical conditions. There are three separate, but interrelated, goals of cognitive-behavioral interventions for medical conditions: quality of life, health outcomes, and health care utilization and cost. The goals of these interventions are to affect three cognitive change processes: correcting misconceptions or omission in verbally accessible knowledge, modifying nonconscious schemata, and modifying self-regulation. Several directions for future research are noted, including to refine interventions by examining the relative contribution to specific change processes to treatment outcome. ========================================
Title: Image control and symptom expression in posttraumatic stress disorder. Author(s)/Editor(s): Laor, Nathaniel; Wolmer, Leo; Wiener, Zeev; Weizman, Ronit; Toren, Paz; Ron, Samuel Source/Citation: Journal of Nervous & Mental Disease; Vol 187(11) Nov 1999, US: Lippincott Williams & Wilkins; 1999, 673-679. Abstract/Review/Citation: Despite the devastating impact of affective dysregulation in posttraumatic stress disorder (PTSD), there has been little research on how trauma relates to affect regulation. This study examines the relationship between the cognitive capacity to control mental images and symptoms of Israeli individuals with (N = 23) and without (N = 23) PTSD after exposure to SCUD missile attacks during the Gulf War. The capacity to control mental images, symptoms of posttrauma, anxiety, and anger were assessed. PTSD Ss with a high image control reported a higher capacity to control anger, lower levels of anger state and expression, and lower levels of intrusive symptoms compared with PTSD subjects with low image control. In individuals without PTSD, results show that the better the image control, the lower the control of anger and the higher the expression of anger. Image control seems to play different functions in the emotional regulation of normal subjects (facilitatory) and PTSD patients (protective). ========================================
Title: Object relations, ego development, and affect regulation in severely addicted substance abusers. Author(s)/Editor(s): Santina, Maureen Rose Source/Citation: Dissertation Abstracts International: Section B: The Sciences & Engineering; Vol 59(11-B) Jun 1999, US: Univ. Microfilms International; 1999, 6077 Abstract/Review/Citation: Fifty severely addicted substance abusers were compared to 50 nonaddicted controls on measures of object relations, alexythymia, ego development, psychopathology, and experienced level of childhood trauma. Substance abusers were selected from residents at a therapeutic community program, and were all diagnosed with severe chemical dependency. Controls were selected from volunteers who responded to ads placed in supermarkets, and were screened to eliminate subjects who reported substance abuse problems. Subjects were administered the Bell Object Relations and Reality Testing Inventory (BORRTI), the Sentence Completion Test for ego development, the Toronto Alexythymia Scale, the Symptom Checklist-90, and the Childhood Trauma Questionnaire. Data were analyzed using univariate ANOVAs and discriminant analysis to evaluate differences between groups on each variable, and Pearson's r was used to determine correlations between constructs. Substance abusers displayed significant difficulties in several areas: ability to recognize, differentiate and ameliorate emotions; difficulties in forming secure, gratifying, and supportive relationships; chronic feelings of alienation and isolation; and egocentricity. Addicts reported significantly greater levels of experienced childhood trauma and psychopathology than did controls. Alexythymia and experienced level of childhood trauma were highly correlated with object relational deficits across the whole sample. Ego development was weakly correlated with some measures and not correlated with others. It was concluded that object relations theories of addiction received empirical support, and that object relational deficits should be addressed in the treatment of addicts. The high level of experienced childhood trauma reported by addicts raised the issue of prevalence of PTSD symptoms among addicts. It was suggested than PTSD and dissociative symptoms may cause clients to discontinue treatment if it is too confrontive. ========================================
Title: Sexual revictimization: Risk factors and prevention. Author(s)/Editor(s): Cloitre, Marylene Source/Citation: Cognitive-behavioral therapies for trauma., New York, NY, US: The Guilford Press; 1998, (xii, 431), 278-304 Source editor(s): Follette, Victoria M. (Ed) Abstract/Review/Citation: Research data indicate that retraumatized women make up the largest subgroup of sexually assaulted women. Given this, sexual assault research should have as a priority the identification of the psychological characteristics of women with a history of childhood sexual abuse that put them "at risk" for adult sexual assault. It is also important to begin developing prevention programs for at-risk women and adolescent girls that target and reduce these risk factors. This chapter reviews the available data on the potential assault risk factors among women with a history of childhood abuse. It also presents a developing model of retraumatization and a cognitive-behavioral intervention designed to reduce risk for repeated sexual assaults. Topics discussed include theoretical orientation: a social-developmental perspective; affect regulation; interpersonal relatedness; posttraumatic stress disorder (PTSD) as a risk factor for retraumatization; a proposed treatment model: skills training in affect and interpersonal relatedness regulation/prolonged exposure; assessment; guidelines for selection; and clinical application. ========================================
Title: Emotional suppression heightens autonomic response to trauma cues in posttraumatic stress disorder. Author(s)/Editor(s): Rich, Martina Renee Source/Citation: Dissertation Abstracts International: Section B: The Sciences & Engineering; Vol 59(4-B) Oct 1998, US: Univ. Microfilms International; 1998, 1866 Abstract/Review/Citation: Increased physiological responding to trauma-related stressor stimuli has been consistently found among patients with posttraumatic stress disorder (PTSD). Recent research on emotion regulation has demonstrated that efforts to suppress expressions of emotion when viewing evocative stimuli increase sympathetic activation. The present study tests the hypothesis that when patients with PTSD attempt to cope with trauma-related physiological changes by suppressing emotions, they increase their autonomic arousal. 32 Vietnam combat veterans with PTSD and 28 veterans with mixed psychiatric (non-PTSD) diagnoses were shown a videotape of combat scenes while physiological, affective, and behavioral responses were recorded. One-half of the subjects in each group were instructed to suppress all expression of emotion while watching the tape. As predicted, PTSD subjects who were instructed to suppress showed greater increases in skin conductance levels than nonsuppressing PTSD subjects. Experimental condition did not affect physiological responding among subjects without PTSD. The results suggest that suppression of emotional expressiveness may interfere with habituation and prolong physiological arousal when patients with PTSD encounter evocative trauma-related stimuli. ========================================
Title: Validation of the Structured Interview for Disorders of Extreme Stress. Author(s)/Editor(s): Zlotnick, Caron; Pearlstein, Teri Source/Citation: Comprehensive Psychiatry; Vol 38(4) Jul-Aug 1997, US: WB Saunders & Co; 1997, 243-247 Abstract/Review/Citation: Examined the construct validity of the subscales of the Structured Interview for Disorders of Extreme Stress (SIDES), a measure of the associated features of posttraumatic stress disorder (PTSD). Using a clinical sample of 74 survivors of childhood sexual abuse with PTSD, this study demonstrated that the subscales of the SIDES (alterations in regulation of affect and impulses, alterations in attention or consciousness, alterations in self-perception, and somatization) correlated highly with instruments hypothesized to measure similar constructs. Divergent validity was established for each of 4 subscales of the SIDES. Findings from this study and other research on the psychometrics of the SIDES indicate that it is a valid measure of the associated features of PTSD in survivors of childhood sexual abuse. ========================================
Title: Dissociation, somatization, and affect dysregulation: The complexity of adaption to trauma. Author(s)/Editor(s): van der Kolk, Bessel A.; Pelcovitz, David; Roth, Susan; Mandel, Francine S.; et al Source/Citation: American Journal of Psychiatry; Vol 153(Suppl) 1996, US: American Psychiatric Assn; 1996, 83-93 Abstract/Review/Citation: Investigated the relationships between exposure to extreme stress, the emergence of PTSD, and symptoms traditionally associated with hysteria, which can be understood as problems with stimulus discrimination, self-regulation, and cognitive integration of experience. The Mental Disorders-IV (DSM-IV) field trial for PTSD studied 395 traumatized treatment-seeking Ss and 125 non-treatment-seeking Ss (all Ss mean age 37.1 yrs) who had also been exposed to traumatic experiences. Results show PTSD, dissociation, somatization, and affect dysregulation were highly interrelated. The Ss meeting the criteria for lifetime (but not current) PTSD scored significantly lower on these disorders than those with current PTSD, but significantly higher than those who never had PTSD. Ss who developed PTSD after interpersonal trauma as adults had significantly fewer symptoms than those with childhood trauma, but significantly more than victims of disasters. ========================================
Title: Stages of decompensation in combat-related posttraumatic stress disorder: A new conceptual model. Author(s)/Editor(s): Wang, Sheila; Wilson, John P.; Mason, John W. Source/Citation: Integrative Physiological & Behavioral Science; Vol 31(3) Jul-Sep 1996, US: Transaction Periodicals Consortium; 1996, 237-253 Abstract/Review/Citation: This conceptual article presents a model of severe, chronic combat-related posttraumatic stress disorder (PTSD) based on several years of longitudinal clinical observations of Vietnam veterans. The model describes a repeating cycle of decompensation that profoundly disrupts the veteran's life. There appear to be "stages" of decompensation that can be described clinically and may be distinct physiologically. The stages describe a wide range of functioning, from adaptive to totally dysfunctional. PTSD core symptoms, as well as several other dimensions of clinical functioning, such as affect regulation, defenses, ego states, interactions with the environment, capacity for self-destruction/suicide and capacity for attachment and insight are described for each stage. Clinical and research implications are discussed. ========================================
Title: Thinking about feelings: Affect tolerance, affect regulation and response to psychological trauma. Author(s)/Editor(s): Ansorge, Susan Beth Source/Citation: Dissertation Abstracts International: Section B: The Sciences & Engineering; Vol 56(6-B) Dec 1995, US: Univ. Microfilms International; 1995, 3430 Abstract/Review/Citation: Current models of Post-traumatic Stress Disorder (PTSD) do not adequately address the specific processes and mechanisms underlying impairments in emotional processing and functioning within the disorder. Recently, the ways that individuals think about their feelings (i.e., evaluate, tolerate and attempt to regulate their emotional experience) have been identified as playing a central role in successful affective functioning. The present study concerns the role of these processes in psychological responses to traumatic events. Specifically, a model of emotional functioning that accounts for relationships between cognitions about emotions, responses to trauma-related stimuli and PTSD symptomatology is investigated in a sample of 61 combat-exposed Vietnam veterans (32 PTSD, 29 Well-adjusted). Key areas which have recently shown to be influential in modulating emotions are: (1) the meta-experience of emotion (i.e., reflective thoughts about feelings); (2) generalized expectancies about one's ability to regulate affect; and (3) moment-to-moment thoughts denoting 'openness' to emotional responses. Measured after exposure to a trauma-related stimulus, openness is construed here as a correlate of the capacity to 'process' trauma-related emotions, which has been identified as a central requirement for adequate integration and adjustment to a traumatic event. These findings suggest that the ways in which individuals evaluate and attempt to regulate emotions has relevance to their cognitive and affective responses to trauma-reminders, to their ability to recover from exposure to a trauma-stimulus, and to specific PTSD symptomatology. Additionally, it appears that relative to well-adjusted combat veterans, subjects with PTSD: (1) report less acceptance of and clarity about their emotions, (2) believe that their feelings have more influence on their thoughts and judgments, (3) are less likely to attempt to repair negative emotional states and to maintain positive ones. ========================================
Title: Clinical presentation of disorders of extreme stress in combat veterans. Author(s)/Editor(s): Newman, Elana; Orsillo, Susan M.; Herman, Debra S.; Niles, Barbara L.; et al Source/Citation: Journal of Nervous & Mental Disease; Vol 183(10) Oct 1995, US: Lippincott Williams & Wilkins; 1995, 628-632. Abstract/Review/Citation: Assessed 10 male combat veterans (mean age 47.4 yrs) for the presence or absence of disorders of extreme stress (DES) in order to provide descriptive clinical information about the severity and patterns of endorsement of DES symptoms among combat veterans. All Ss technically met criteria for the DES symptom constellation, yet only few symptoms were endorsed by a significant proportion of Ss at a moderate severity level. The DES categories that were most applicable include: problems with affect regulation, amnesia for important life events, feelings as if one is permanently damaged, feeling as if no one understands, feeling unable to trust, despair, and feeling a loss in life's meaning. These problem areas are not covered under the posttraumatic stress disorder (PTSD) diagnosis. ========================================
Title: The effects of trauma on young children: A case of 2-year-old twins. Author(s)/Editor(s): Osofsky, Joy D.; Cohen, Geraldine; Drell, Martin Source/Citation: International Journal of Psycho-Analysis; Vol 76(3) Jun 1995, England: Institute of Psychoanalysis; 1995, 595-607 Abstract/Review/Citation: Explores effects of trauma of young children in the context of chronic community and family violence. Features of adult posttraumatic stress disorder (PTSD) have been identified in children aged <4 yrs. External events can affect intrapsychic structure and development of the self. A case is presented of 2-yr-old male twins treated with psychoanalytically-informed play psychotherapy 7 mo after witnessing the shooting death of their mother by their father. Through emotional availability and attention to affect regulation, the therapist showed sensitivity to the Ss' inner and outer worlds, helping to contain overwhelming affects as they played out conflicts and fears symbolically in fantasy play. While the therapist facilitated working through of Ss' sense of helplessness, lack of control, and anxiety to gain a sense of mastery, systematic follow-up is needed to determine the later developmental course. (French, German & Spanish abstracts)
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