Posttraumatic and Acute Stress Disorders

By Matthew J. Friedman

A handy, easy-to-read reference for the diagnosis and treatment of posttraumatic and acute stress disorders, this important 6th edition has been revised and updated extensively, offering a wealth of new information in a concise format of 6 sections. The new DSM-5 diagnostic criteria for PTSD and Acute Stress Disorder (ASD) are discussed, in depth, in Chapters 2 and 6, respectively. In addition, updated tables listing instruments for assessing diagnosis and symptom severity are cited and annotated in seven appendices, as in previous editions. Chapters 3-5 have been revised to keep pace with the ever-expanding literature on treatment of PTSD. This is especially true in Chapter 4 where, in addition to a focus on evidence-based cognitive-behavioral therapy, CBT and other individual psychosocial treatments (e.g. eye movement desensitization and reprocessing, EMDR), the growing literature is presented on couples, family, group and school-based treatments for adults, children and adolescents. Chapter 5 reviews the pathophysiology of PTSD and evidence-based pharmacotherapy for the disorder. Chapter 6 addresses both normal acute stress reactions and clinically significant ASD, as well as effective interventions for each.

A comprehensive, sophisticated, practical reference for all clinicians, Posttraumatic and Acute Stress Disorders, 6th Edition is an invaluable resource designed to guide the best clinical attention for individuals suffering from posttraumatic an

d acute stress disorders.

• Language: English
• Publisher: Springer
• Release date: Feb 28, 2015
• ISBN: 9783319150666

Book preview

Matthew J. Friedman

Posttraumatic and Acute Stress Disorders6th ed. 2015

A320755_6_En_BookFrontmatter_Figa_HTML.png

Matthew J. Friedman

U.S. Department of Veterans Affairs, National Center for PTSD, White River Junction, VT, USA

Departments of Psychiatry and Pharmacology & Toxicology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA

ISBN 978-3-319-15065-9e-ISBN 978-3-319-15066-6

DOI 10.1007/978-3-319-15066-6

Springer Cham Heidelberg New York Dordrecht London

Library of Congress Control Number: 2015930205

© Springer International Publishing Switzerland 2015

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To Gayle and Dick

Preface

Although the basic format hasn’t changed, this sixth edition of Posttraumatic and Acute Stress Disorders has been revised extensively. First of all, the new DSM-5 diagnostic criteria for PTSD and acute stress disorder (ASD) are discussed, in depth, in Chaps. 2 and 6 , respectively. In addition, updated tables listing instruments for assessing diagnosis and symptom severity are cited and annotated in seven Appendices, as in previous editions. Separate lists are shown for adults and children and adolescents.

Second, thanks to remarkable progress in clinical trials research, Chaps. 3 – 5 have also been revised to keep pace with this expanding literature. This is especially true in Chap. 4 where, in addition to a focus on cognitive-behavioral therapy and other individual psychosocial treatments (e.g., eye movement desensitization and reprocessing, EMDR), the growing literature is presented on couples, family, group, and school-based treatments for adults, children, and adolescents. There are also sections on applications of technology to facilitate treatment by utilizing telehealth, the Internet, and mobile apps. In addition, Chap. 5 updates our psychobiological understanding of PTSD and presents the latest information on evidence-based pharmacotherapy for the disorder.

Finally, Chap. 6 addresses both normal acute stress reactions and clinically significant ASD. Besides a review of diagnostic and treatment issues, it addresses our emerging understanding of resilience and how such knowledge may guide preventive public health approaches in order to ameliorate the extreme distress caused by exposure to traumatic events.

Don’t let the size of this book fool you. Although it is concise, it leaves few trauma-related stones unturned with regard to assessment and treatment. And for those inspired to learn more about any specific topic, the extensive bibliography is a good place to start. In short, this little book is a comprehensive, sophisticated, updated, and practical resource for clinicians, designed to assist your efforts to provide the best clinical attention to individuals suffering from posttraumatic and acute stress disorders.

Matthew J. Friedman

White River Junction, VT

Contents

1 Overview of Posttraumatic Stress Disorder (PTSD) 1

What Is Trauma?​ 2

What Is the History and Prevalence of PTSD?​ 3

Historical Overview 3

Prevalence 4

Can PTSD Be Prevented?​ 4

How Severe and Chronic Is PTSD?​ 5

References 7

2 Recognizing, Diagnosing, and Assessing PTSD 9

What Are the Main Characteristics of PTSD?​ 9

Classification of PTSD in DSM-5 10

What Are the DSM-5 Diagnostic Criteria for PTSD? 11

The Traumatic Stress Criterion 11

Multiple Traumas 16

Introduction to Symptoms of PTSD 16

Intrusion Symptoms 16

Avoidance Symptoms 17

Negative Alterations in Cognitions and Mood 17

Preschool Subtype 19

Dissociative Subtype 19

Delayed Expression 20

DSM-5 Diagnostic Thresholds 20

How Should Clinicians Approach Initial Patient Interviews?​ 25

Risk Factors for PTSD 26

What Tools Are Available for Diagnosing PTSD?​ 27

How Do You Differentiate PTSD from Comorbid and Other Disorders?​ 29

Traumatic Brain Injury 29

Other Posttraumatic Problems 31

References 33

3 Global Treatment Issues for PTSD 35

What Are the Timing and Priority Issues Related to Treatment?​ 35

Timing Issues for Seeking Treatment 36

Priority Issues for Treatment 37

What General Considerations Exist for Choosing a Specific Treatment Option?​ 37

What PTSD Treatment-Focus Issues Exist?​ 38

Trauma-Focused Therapy 38

Trauma Focus vs.​ Supportive Therapy 38

Combined Treatment 40

Treatment of Comorbid Disorders 41

Environmental Considerations 42

Complex PTSD 43

Cross-Cultural Considerations 44

Recovered Memories 45

What Are the Major Personal Issues for Clinicians Treating Those with PTSD?​ 46

Therapeutic Neutrality vs.​ Advocacy 47

Vicarious Traumatization 47

Countertransfere​nce 48

Clinician Self-Care 49

Key Concepts 49

References 50

4 Psychological Treatments for PTSD 53

What Specific Psychosocial Treatments Are Available for Adults with PTSD?​ 53

Psychoeducation 54

Psychoeducation to Initiate Therapeutic Activity 55

Psychoeducation Through Peer Counseling 57

Individual Psychotherapies 58

Cognitive Behavioral Therapy 58

Technological Delivery of CBT:​ Virtual Reality, Internet Approaches, and Telehealth Interventions 66

Eye Movement Desensitization and Reprocessing 68

Psychodynamic Psychotherapy 69

Couples/​Family Therapy 74

Group Therapies 75

Hypnosis 78

Social Rehabilitative Therapies 78

What Psychosocial Treatments Are Available for Children and Adolescents?​ 79

CBT for Children and Adolescents 79

Other Promising CBT Approaches 80

Group School-Based Treatments for Children and Adolescents 80

Psychodynamic Therapy for Child Trauma 81

Summary 82

Creative Arts Therapies for Children and Adults 82

Combined Treatments 82

Key Concepts 83

References 84

5 Pharmacological Treatments for PTSD 93

How Does the Human Stress Response Occur?​ 93

Fight, Flight, or Freeze Reaction 94

The General Adaptation Syndrome 95

What Psychobiological​ Abnormalities Occur in Those with PTSD?​ 97

Adrenergic System 98

HPA System 99

Serotonergic System 99

Neurotransmissio​n 100

How Can Medications Best Be Used to Treat PTSD?​ 100

Selective Serotonin Reuptake Inhibitors 105

Other Second-Generation Antidepressants 107

Monoamine Oxidase Inhibitors 107

Tricyclic Antidepressants 107

Antiadrenergic Agents 108

Anticonvulsants/​Mood Stabilizers 109

Benzodiazepines 109

Antipsychotic Agents 110

Resilience and Prevention 110

References 112

6 Strategies for Acute Stress Reactions and Acute Stress Disorder (ASD) 115

From the Patients’ Perspective 116

Military Considerations 117

What are Normal Acute, Posttraumatic Distress Reactions?​ 118

Counseling the Patient with an Acute Stress Reaction 119

What Treatment Approaches are Used for Traumatic Event Survivors?​ 119

Forward Psychiatry for Combat Operational Stress Reaction (COSR) 120

Resilience 121

Psychological Debriefing 122

Psychological Debriefing Effectiveness in Preventing Later PTSD 123

What is Acute Stress Disorder?​ 124

What Challenges Exist for Diagnosing ASD?​ 125

Risk Factors for ASD 125

Distinguishing ASD from PTSD 125

Understanding DSM-5 Diagnostic Criteria 126

Conducting a Clinical Interview for ASD 128

ASD Assessment and Diagnostic Tools 128

Is There a treatment for ASD?​ 129

Cognitive Behavioral Therapy 129

Treating Acutely Traumatized Children 130

Key Concepts 131

References 132

Appendix A137

Glossary143

Bibliography147

Index151

© Springer International Publishing Switzerland 2015

Matthew J. FriedmanPosttraumatic and Acute Stress Disorders10.1007/978-3-319-15066-6_1

1. Overview of Posttraumatic Stress Disorder (PTSD)

Matthew J. Friedman¹, ² 

(1)

U.S. Department of Veterans Affairs, National Center for PTSD, White River Junction, VT, USA

(2)

Departments of Psychiatry and Pharmacology & Toxicology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA

Keywords

TraumaPTSDPrevalencePreventionResilienceSymptom severityChronicityClinical course

This Chapter Answers the Following Questions

What is trauma?—This section defines trauma, the necessary precursor to PTSD.

What is the history and prevalence of PTSD?—This section reviews how PTSD has been viewed since ancient times and presents information on how common PTSD is worldwide.

Can PTSD be prevented?—This section offers recommendations for promoting resilience among those at risk for PTSD.

How severe and chronic is PTSD?—This section identifies three general categories of PTSD sufferers: those with lifetime PTSD, those in remission but experiencing occasional relapses, and those with delayed onset.

During the course of a lifetime, everyone is exposed to stressful events such as failure, disappointment, rejection, and loss. Most of the time, most of us have the psychological capacity to cope successfully with such events and to continue our lives pretty much as before. Sometimes we are confronted by terrifying, catastrophic, or severely stressful (e.g., traumatic) events in which there is a real possibility that we and/or a loved one might be killed, seriously injured, or sexually violated. As with less stressful events, most of us are resilient and will bounce back from the emotional distress or functional impairment that we experienced during the traumatic event. A significant minority of us, however, will be unable to cope psychologically with such traumatic stress. We will not bounce back but, instead, will develop the serious and potentially incapacitating symptoms that characterize posttraumatic stress disorder (PTSD).

In the USA, approximately half of all Americans will be exposed to at least one traumatic event, such as assault, military combat, an industrial or vehicular accident, rape, domestic violence, or a natural disaster (e.g., an earthquake). Traumatic exposure is higher for individuals who engage in professions where their work places them in traumatic situations on a regular basis; this includes military personnel, police, firefighters, emergency medical technicians, and others. Exposure to extreme stress is also much higher for people who live in nations subjected to war, state terrorism, or forced migration, such as Syria, Algeria, Cambodia, Palestine, or Iraq. In other words, there is a dose-response relationship between the amount of exposure to traumatic events and the likelihood of developing PTSD. For example, whereas approximately 8 % of Americans develop PTSD, in areas of conflict, PTSD prevalence is 20–30 % [1, 2].

We should emphasize that this represents a minority of all individuals exposed to traumatic events. Most people are resilient and can absorb the psychological impact of such experiences and resume their normal lives; however, a sizeable number cannot. This book is about the latter group, the minority of trauma-exposed individuals who develop PTSD. We will also discuss the resilient majority in Chap. 6.

PTSD is a disorder in which a person experiences trauma-related symptoms or impairments in everyday functioning that last for at least a month and sometimes for life. It has been recognized by many other names since antiquity and by modern psychiatry since the late 1800s. Although the specific symptoms included in the original PTSD diagnostic criteria [3] have been partially modified, the fundamental PTSD construct that exposure to catastrophic psychological stress can produce severe, debilitating and long-lasting distress and impairment, has clearly withstood the test of time. As a result, clinicians have had almost 35 years in which to utilize PTSD as a diagnostic tool and to develop effective treatments.

Although PTSD can only be diagnosed 1 month after an individual has been exposed to trauma, many people experience great distress during the immediate aftermath of a traumatic event, including having nightmares and avoiding people and places that may remind them of the trauma. Such acute, posttraumatic reactions will be considered in Chap. 6.

What Is Trauma?

When trauma was first introduced as a construct in the DSM-III (1980), it was defined as a catastrophic stressor that would evoke significant symptoms of distress in most people [3]. At that time, trauma was thought to be a rare and overwhelming event—generally outside the range of usual human experience—that differed qualitatively from common experiences, such as bereavement, chronic illness, business losses, or marital conflict. Traumatic events cited in the DSM-III included rape, assault, torture, incarceration in a death camp, military combat, natural disasters, industrial/vehicular accidents, or exposure to war/civil/domestic violence.

Trauma is currently defined as a catastrophic event (or series of events) in which individuals have been exposed to situations in which they were personally threatened or witnessed death, physical harm, or sexual violence. Trauma also includes indirect exposure in which a loved one is exposed to trauma or in which individuals repeatedly confront the consequences of trauma (e.g., body parts in a war zone after a battle) in the line of professional duties. We will discuss this in much more detail in Chap. 2.

From the Patient’s Perspective

That lawyer called again. He thinks I’ve got a great case against the trucking company and could win a huge settlement. It’s tempting. I certainly need the money. But every time I even think about the accident (like now), I go to pieces. And—if I start to talk about it—I get terrified. Then the nightmares. No sleep. That horrible jumpy feeling. And I turn into a nervous wreck. It isn’t worth it, even if I could win a million bucks! I’ll just have to call him back tomorrow and tell him I’m not interested. He’ll have to find someone else to sue.

Catastrophic events are not rare. Today, our understanding about trauma has changed significantly from that first described in the DSM-III since exposure to traumatic events is not unusual. Indeed, research has shown that over half of all American men (60.7 %) and women (51.2 %) are likely to be exposed to at least one catastrophic event during their lives [1]. Exposure is much higher in countries torn by war, civil strife, genocide, state-sponsored terrorism, or other forms of violence. For example, exposure to trauma was reportedly as high as 92 % in Algeria, where deadly conflict and violence have persisted for years [2]. As a result of these findings, the original DSM-III concept of trauma as an event beyond the range of normal human experience has been changed in subsequent editions of the Diagnostic and Statistical Manual (e.g., DSM-IV, 1994; DSM-IV-TR, 2000; and DSM-5; 2013) [4–6] which no longer characterize trauma exposure as a rare event. Indeed, from a global perspective, exposure to catastrophic stress is a common fact of life.

What Is the History and Prevalence of PTSD?

Historically, poets and writers have recognized that exposure to trauma may produce enduring psychological consequences. Various literary works—Homer’s Iliad, Shakespeare’s Henry IV, and Dickens’s Tale of Two Cities—present characters’ psychological transformations and symptoms related to trauma. Even Harry Potter was perhaps traumatized when, as an infant, he witnessed his parents’ murder by the evil wizard Lord Voldemort (Mueser, K. Personal communication. 2003).

Historical Overview

In the late nineteenth century, clinicians also began to focus on the psychological impact of military combat among veterans of the US Civil War and the Franco-Prussian War. Clinical formulations on both sides of the Atlantic focused either on cardiovascular (e.g., soldier’s heart, Da Costa’s syndrome, neurocirculatory asthenia) or psychiatric (e.g., nostalgia, shell shock, combat fatigue, war neurosis) symptoms [7, 8]. Similar clinical presentations among nineteenth-century civilian survivors of train accidents were called railway spine [9]. Throughout this period, clinicians asked to provide treatment for survivors of military or civilian trauma were struck by the physiological as well as the psychological symptoms exhibited. Indeed, by the 1940s, Abram Kardiner, an American psychiatrist who worked extensively with World War I veterans suffering from war neurosis, was so impressed by their excessive startle reactions that he called it a physioneurosis [10]. to characterize the significant physiological as well as psychological symptoms that he considered key components of the war neurosis syndrome. Chapter 5 reviews some of the major biological abnormalities that are central to this disorder.

Prevalence

With the growing recognition that catastrophic stress and traumatic events are much more common than originally suspected, it is clear that PTSD is a significant public health problem. Although over half of all American adults will have been exposed to a catastrophic stress event (60 % men and 51 % women), only 6.8 % (3.6 % men and 9.6 % women) will have developed PTSD at some point in their lives [1]. This means that millions of Americans will suffer from this disorder, and PTSD is a major public health problem in the USA and elsewhere. If untreated, many of these individuals will never recover. Research with veterans of World War II and survivors of the Nazi Holocaust has shown, for example, that PTSD can persist for more than 50 years or for a lifetime [11].

Worldwide, the psychological and physical consequences of traumatic exposure constitute a