Posttraumatic Stress Treatments

Phobia Release Program

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Phobia Release Program Overview


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Posttraumatic Stress Disorder Definitions

The DSM-IV defines an exposure to a traumatic event as experiencing or witnessing actual or threatened death or serious injury and responding with intense fear, helplessness, or horror. In children, the response may be manifested as disorganized or agitated behavior. A trauma history is a necessary, but not sufficient, condition for the presence of PTSD. PTSD also requires that the traumatic event be persistently experienced through intrusive recollections, dreams or responses to associated cues, persistent avoidance of stimuli asso ciated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal, including sleep difficulties, irritability, and exaggerated startle response. While there has been relatively little research to indicate the prevalence of PTSD in adolescents, high rates of victimization (130) and PTSD (2) in community adolescent samples suggest that understanding the relationships with adolescent SUD is an important priority.

Posttraumatic Stress Disorder In Adults

Posttraumatic Stress Disorder (PTSD) is an extreme psy-chobiological reaction to a psychologically traumatic event characterized by profound disturbances in cognitive, behavioral, and physiological functioning. The diagnosis is applied when an individual has experienced, witnessed, or been confronted with an event involving perceived or threatened loss of life, serious injury, or loss of physical integrity and which evoked intense fear, helplessness, or horror. The types of events that may cause PTSD include sexual or physical assault, military combat, motor vehicle accidents, major disasters, and acts of terrorism. In the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) symptoms of PTSD are organized under three clusters (1) reexperiencing (e.g., intrusive thoughts, nightmares, flashbacks, and psycho-physiological reactivity to reminders of the trauma) (2) avoidance and emotional numbing (e.g., avoiding stimuli associated with the trauma, and inability...

Assessment and Treatment of PTSD

A comprehensive clinical assessment of PTSD should include administration of structured diagnostic interviews, self-report psychometrics, and an evaluation of trauma across the lifespan. Several structured interviews are available and the Clinician-Administered PTSD Scale for the DSM-IV and PTSD module of the Structured Clinical Interview for the DSM-IV have become standards in the field. Self-report instruments can also assist in diagnosis or provide efficient, low-cost assessment methods for research and screening purposes. Of these, several were constructed specifically for assessing PTSD (e.g., Mississippi Scale for Combat-related PTSD PTSD Checklist PTSD Diagnostic Scale). Others were derived from the existing items of major inventories such as the Minnesota Multiphasic Personality Inventory and the Symptom Checklist-90. Finally, instruments such as the Potential Stressful Events Interview and the Traumatic Stress Schedule are used to evaluate trauma across the lifespan....

Psychological Sequelae to Trauma Posttraumatic Stress Disorder

In order to be diagnosed with posttraumatic stress disorder (PTSD), an individual must experience a traumatic event in which he or she feels threatened with death or serious injury and experiences intense emotions, such as fear, helplessness, or horror. Exposure to such a traumatic event results in three clusters of pathological symptoms reexperiencing, avoidance, and arousal (ApA, 2000). The trauma may be reexpe-rienced through intrusive memories, nightmares, flashbacks, or psychological or physiological distress at reminders of the trauma. The avoidance cluster of symptoms includes avoidance of any stimuli reminiscent of the trauma (from places and people to subjective thoughts and feelings), as well as a general numbing of responsiveness (e.g., feeling detached from others or having a restricted range of affect). Finally, individuals with PTSD suffer from arousal symptoms such as insomnia, irritability, difficulty concentrating, hy-pervigilance, and an exaggerated startle response....

Case Illustration of the Current Findings Dealing with Post Traumatic Stress Disorder

The described case study may serve also as an illustration of the described earlier neurobiological, cognitive-behavioral and psychodynamic data on PTSD, described earlier. PTSD symptoms, including exaggerated startle response and flashbacks, may be related to a failure of hippocampus and medial cortex to dampen the exaggerated symptoms of arousal and distress that are mediated through the amygdale in response to reminders of the traumatic events the persistent re-experiencing of a traumatic event may be considered as the disability of assimilation and accommodation of the traumatic event by the individual. PTSD becomes persistent when a person processes trauma in a way that leads to an ongoing sense of serious and current threat the real danger is only a rationalization of persistent hyper-vigilance and a strive for full control. Persons with PTSD have higher arousal of a sympathetic system at the time of conditioning and therefore are more prone to conditioning than the...

Disintegration of Experience Accompanying PTSD

In a series of studies we demonstrated that memories of trauma initially tend to have few autobiographical elements When PTSD patients have their flashbacks, the trauma is relived as isolated sensory, emotional, and motoric imprints, without much of a storyline. We have shown this in victims of childhood abuse (van der Kolk and Fisler, 1995), assaults, and accidents in adulthood (van der Kolk et al., 1997) and in patients who gained awareness during surgical procedures (van der Kolk et al., 2000). These studies support the notion that traumatic memories result from a failure of the CNS to synthesize the sensations related to the event into an integrated semantic memory. While most patients with PTSD construct a narrative of their trauma over time, it is characteristic of PTSD that sensory elements of the trauma itself continue to intrude as flashbacks and nightmares, in states of consciousness where the trauma is relived, unintegrated with an overall sense of current time, place, and...

Hormonal Response in Posttraumatic Stress Disorder

In a well-functioning person, stress produces rapid and pronounced hormonal responses. However, chronic and persistent stress inhibits the effectiveness of the stress response and induces desensitization. PTSD develops following exposure to events that overwhelm the individual's capacity to reestablish homeostasis. Instead of returning to baseline, there is a progressive kindling of the individual's stress response. Initially only intense stress is accompanied by the release of endogenous, stress-responsive neurohormones, such as cortisol, epinephrine, norepinephrine (NE), vasopressin, oxytocin, and endogenous opioids. In PTSD even minor reminders of the trauma may precipitate a full-blown neuroendocrine stress reaction It permanently alters how an organism deals with its environment on a day-to-day basis, and it interferes with how it copes with subsequent acute stress. A review of the neuroendocrine findings in PTSD to date shows very specific abnormalities in this disorder,...

Hemispheric Lateralization in PTSD

Both Rauch et al. (1996) and Teicher and his group (2002) found marked hemispheric lateralization in PTSD subjects who were exposed either to a negative memory or to a personalized trauma script. This suggests that there is differential hemispheric involvement in the processing of traumatic memories. The right hemisphere, which developmentally comes on-line' earlier than the left hemisphere (Schore, 1994), is involved in the expression and comprehension of global nonverbal emotional communication (tone of voice, facial expression, visual spatial communication), and allows for a dynamic and holistic integration across sensory modalities (Davidson, 1989). This hemisphere is particularly integrated with the amygdala, which assigns emotional significance to incoming stimuli and helps regulate the autonomic and hormonal responses to that information. While the right hemisphere is specialized in detecting emotional nuances, it has only a rudimentary capacity to communicate analytically, to...

An Application of the Information Metabolism Model to a Comprehensive Synthesis of the Data on Post Traumatic Stress

Subjective experiences in PTSD may be understood as a manifestation of an insufficient ability to assimilate a traumatic experience to the mental structures and to accommodate them to this information, that are responsible for Some symptoms of PTSD are consequences of dysfunctional beliefs and intrapsychic conflicts (in centers of decision-making) that are related to maladaptive reactions to stress and disturbances coming from experiencing traumatic events, Formation of PTSD symptoms may be facilitated by PTSD becomes persistent when a person processes trauma in a way that leads to an ongoing sense of serious and current threat (Ehlers, Clark, 2000). Traumatic events may resonate with childhood traumas. failure of hippocampus to dampen the exaggerated symptoms of arousal and distress in response to reminders of the traumatic events, persons with PTSD have higher arousal of a sympathetic system at the time of conditioning and therefore are more prone to conditioning than the...

Current Knowledge on Mechanisms of Pathological Responses to Traumatic Events

The main neurobiological findings dealing with the influence of trauma on an individual's life were summarized in neuroanatomic model of PTSD (Stein, 2000) that includes Failure of higher brain regions in extinguishing conditioned fear responses may partly explain symptomatology associated with PTSD. Generally, symptoms of PTSD, including exaggerated startle response and flashbacks, may be related to a failure of hippocampus and medial cortex to dampen the exaggerated symptoms of arousal and distress that are mediated through the amygdala in response to reminders of the traumatic events. The main cognitive behavioral findings concerning PTSD (Hollander, Simeon, 2003) include the following PTSD becomes persistent when a person processes trauma in a way that leads to an ongoing sense of serious and current threat (Ehlers, Clark, 2000). Persons with PTSD have higher arousal of a sympathetic system at the time of conditioning and therefore are more prone to conditioning than the...

Hippocampus in PTSD

A number of PTSD studies have reported significantly decreased hippocampal volume in patients with PTSD (e.g., Bremner 1997, 1999 Gurvits et al., 1998) and depression. For example, Bremner et al. (1997) compared hippocampal volume in adult survivors of childhood abuse to matched controls. PTSD patients had a 12 percent smaller left hippocampal volume relative to the matched controls (p < .05), without smaller volumes of comparison regions (amygdala, caudate, and temporal lobe), while Gurvits and her colleagues found both significantly smaller left and right hippocampi in combat veterans with PTSD compared to combat controls without PTSD and normal controls. However, several well-controlled studies have failed to replicate these findings (e.g., DeBellis et al., 1999 Bonne et al., 2001). In the studies in which hippocampal atrophy has been found, investigators have proposed that excessively high levels of cortisol caused hippocampal cell death, resulting in hippocampal atrophy. At...

Neuroimaging of Fear Anxiety

1999) and vocalizations (Phillips et al., 1998), as well as in response to aversive pictures (Garrett and Maddock, 2001), and in human adaptations of animal paradigms of conditioned fear (LaBar et al., 1995 Morris et al., 1998 Whalen et al., 1998), to aversive auditory, olfactory and gustatory stimuli (Zald, 2003), and to exposure to procaine and inhalation of CO2 (Ketter et al., 1996 Brannan et al., 2001). These combined findings suggest a general role for the amygdala in the automatic, preconscious early detection of threat and danger in the environment, and possibly in triggering the experience of fear anxiety. Interestingly, amygdalar responses to fearful faces are increased in childhood and adolescence (Killgore et al., 2001) and in childhood anxiety and in posttraumatic stress disorder (PTSD) patients (Thomas et al., 2001 Hull, 2002).

Behavioral Inhibition

Although Pavlov emphasized the importance of inhibitory conditioning, the idea was not initially well received. Interest in inhibitory conditioning was reawakened with the incorporation of inhibitory conditioning into correlative accounts of conditioning (e.g., Rescorla, 1967). During this time, the concept of inhibition also proved to be a powerful vehicle for understanding a wide range of clinically relevant behavioral phenomena. Of special interest was the persistence of phobic avoidance in the absence of further traumatic events. But the key development was Rescorla's (1969) introduction of the summation and retar

Death Loss And Trauma Major Loss as a Unifying Construct

This article will provide a brief survey of the fields of work on death, loss, and trauma. The field of death and dying focuses almost exclusively on the dying process and various aspects of death. The field of loss and trauma is broader, encompassing both death and various types of major loss events, including dissolution of close relationships, loss of health, loss of possessions, violation of self as in rape, and losses occurring in traumatic events. Traumatic events are those that inflict major loss, frequently involving violence and multiple deaths. The idea of experiencing a major loss is common to these literatures and integrates a variety of death and loss and trauma concepts and findings. Amajor loss may be defined as a reduction in resources in which the person is emotionally invested. As an example of this synthesis, bereavement and adaptation often are conceived as involving steps common to death and other forms of major loss. Such steps include emotional and cognitive...

Extrahypothalamic CRH Systems

Implications for Biological Psychiatry. The evidence described above clearly points to CRH transmission within discrete regions of the amygdala in the unconditional generation and learned maintenance of fear-related behavior. At the human level, extrahypothalamic CRH has been implicated in a number of human disorders such as major depression (Gold et al., 1996 Nemeroff, 1996), PTSD (Grillon et al., 1996), and bulimia (Krahn and Gosnell, 1989). As a result, the development of novel therapeutic agents that target specific CRH receptor subtypes has become a major thrust in recent years. However, one major problem associated with the use of anti-CRH drugs to treat human clinical populations has been that most of these agents do not pass through the blood-brain barrier efficiently and thus cannot bind to CRH receptors in the necessary neural substrates to effect therapeutic change. As a result, there has been a push in the past decade toward the development of nonpeptide CRH antagonists...

Efficacy Research on Psychotherapy

Posttraumatic Stress Disorder Public speaking anxiety Social Anxiety Disorder (Social Phobia) Specific Phobia Anxiety Disorders. A considerable body of evidence has shown that CBT is as effective as, or more effective than, medications in the treatment of the full range of anxiety disorders (cf. Nathan & Gorman, 1998, for a comprehensive review), Agoraphobia (e.g., Chambless, Foa, Groves, & Goldstein, 1979), Generalized Anxiety Disorder (e.g., Barlow, Rapee, & Brown, 1992), Obsessive-Compulsive Disorder (e.g., Fals-Stewart, Marks, & Schafer, 1993), Panic Disorder (e.g., Barlow, Gorman, Shear, & Woods, 2000), Social Phobia (e.g., Heimberg et al., 1998), and Posttraumatic Stress Disorder (e.g., Foa, Rothbaum, Riggs, & Murdock, 1991).

Structural Abnormalities

Macroscopic anatomical findings in patients with primary affective disorders have been less consistent than those of depressed patients with neurological disorders (reviewed in Harrison, 2002 Soars and Mann, 1997). Brain anatomy is grossly normal, and focal neocortical abnormalities have not been identified using standard structural neuroimaging methods. Focal volume loss has been described using MRI in subgenual medial frontal cortex (Drevets et al., 1997). Also described are small hippocampi in patients with recurrent major depression (Sheline et al., 1999), with a postulated mechanism of glucocorticoid neurotoxicity, consistent with both animal models and studies of patients with posttraumatic stress disorder (Bremner and Narayan, 1998). Nonspecific changes in ventricular size, and T2-weighted MRI changes in subcortical gray and periventricular white matter have also been reported in some patient subgroups, most notably, elderly depressed patients...

Relationships with Substance Use Disorders

Among adolescents, a history of childhood abuse has been found to be associated with high levels of alcohol and drug consumption and related disorders. In a survey of 122,824 public school students in grades 6, 9, and 12, Harrison and colleagues (137) found that physical and sexual abuse histories were associated with an increased likelihood of the use of alcohol, marijuana, and other drugs. This association has been found to be particularly evident for sexual abuse (138-142). High rates of childhood abuse have also been reported among adolescents in treatment for substance-related problems (143,144). Deykin and Buka (145) studied 75 female and 222 male substance-dependent adolescents from seven residential treatment centers. Trauma history was reported by 75 . The lifetime prevalence of PTSD was 45 for females and 24 for males. Among PAARC subjects with alcohol use disorders, trauma history and PTSD are common. Clark, Lesnick, and Hegedus (114) reported trauma rates in adolescents...

Models of Symptom Generation

Sensory and motor effects via unconscious mechanisms, which cause hysterical and other dissociative symptoms. Freud's previously described principle of conversion and repression model of hysteria suggested that psychological conflicts too difficult to process consciously are converted or transformed into physical symptoms. Kardiner and Spiegel (1947) described the traumatic etiology of conversion symptoms and posttraumatic disorders associated with combat experience. They conceptualized such conversion symptoms as a nonverbal language of action, or the expression of conflict over fear and loyalty to comrades, resulting in apparent physical dysfunction that provided an honorable exit from an intolerable situation (Spiegel 1974). They also demonstrated the usefulness of hypnosis in diagnosing and treating both posttraumatic stress disorder and conversion symptoms.

Complexity of Adaptation

Once people develop PTSD, the recurrent unbidden reliving of the trauma in visual images, emotional states, or in nightmares produces a recurrent reliving of states of terror. In contrast to the actual trauma, which had a beginning, middle, and end, the symptoms of PTSD take on a timeless character. The traumatic intrusions themselves are horrifying They interfere with getting over the past, while distracting the individual from attending to the present. The unpredictable exposure to unbidden feelings, physical experiences, images, or other imprints of the traumatic event leads to a variety of (usually maladaptive) avoidance maneuvers, ranging from avoidance of people or actions that serve as reminders to drug and alcohol abuse and emotional withdrawal from friends or activities that used to be potential sources of solace. Problems with attention and concentration keep them from being engaged with their surroundings with zest and energy. Uncomplicated activities like reading,...

Psychophysiological Effects Of Trauma

Posttraumatic stress disorder is not an inevitable outcome of stress Only about 25 percent of individuals who have been exposed to a potential traumatic stressor develop PTSD (Yehuda and McFarlane, 1995). Hence, the central question regarding the biology of PTSD is how to account for the failure of the organism to reestablish its homeostasis and return to its pretraumatic state. Yehuda (2002) has pointed out that understanding the biological response that occurred during the traumatic event does not necessarily address the biology of PTSD. Rather, the central issue appears to be why some people recover and others do not. It also has become clear that PTSD is not an issue of simple conditioning. Many people who have been exposed to an extreme stressor, but who do not suffer from PTSD, become distressed when they are once again confronted with the memory of the tragedy. The critical issue in PTSD is that the stimuli that cause people to overreact may not be conditional enough A variety...

Conditional Responses to Specific Stimuli

Most PTSD sufferers have heightened physiological arousal in response to sounds, images, and thoughts related to specific traumatic incidents, while others have decreased arousal. Initial research on acute trauma victims found that people with PTSD, but not controls, respond to reminders with significant increases in heart rate, skin conductance, and blood pressure (Pitman et al., 1987). The elevated sympathetic responses to reminders of traumatic experiences that happened years, and sometimes decades, ago illustrate the intensity and timelessness with which these trauma imprints continue to affect current experience (Pitman et al., 1987). Post and his colleagues (1992) have shown that life events play a critical role in the first episodes of major affective disorders but become less pertinent in precipitating subsequent occurrences. This capacity of triggers with diminishing strength to produce the same response over time is called kindling. About one third of chronically traumatized...

Hyperarousal to Nontraumatic Stimuli Loss of Stimulus Discrimination

Trauma may result in permanent neuronal changes that have a negative effect on learning, habituation, and stimulus discrimination. The effects of some of these neuronal changes do not depend on actual exposure to reminders of the trauma for expression. The abnormal startle response (ASR) characteristic of PTSD is one example of this phenomenon. Several studies have demonstrated abnormalities in habituation to the ASR in PTSD (e.g., Ornitz and Pynoos, 1989). Interestingly, people who previously met the criteria for PTSD, but no longer do so now, continue to show failure of habituation of the ASR (van der Kolk et al., unpublished data Pitman et al., unpublished data). The failure to habituate to acoustic startle suggests that traumatized people have difficulty evaluating sensory stimuli and mobilizing appropriate levels of physiological arousal. Thus, the problems that people with PTSD have with properly integrating memories of the trauma, tending to get mired in a continuous reliving...

Intergenerational Transmission

In a study of risk factors for the development of PTSD, Yehuda and her colleagues examined the association between cortisol and PTSD in children of holocaust survivors. Low cortisol levels were significantly associated with both PTSD in parents and lifetime PTSD in subjects, whereas having a current psychiatric diagnosis other than PTSD was relatively, but nonsignificantly, associated with higher cortisol levels. Offspring with both parental PTSD and lifetime PTSD had the lowest cortisol levels of all study groups. They concluded that parental PTSD is associated with low cortisol levels in offspring, even in the absence of lifetime PTSD in the offspring. They suggested that low cortisol levels in PTSD may constitute a vulnerability marker related to parental PTSD as well as a state-related characteristic associated with acute or chronic PTSD symptoms (Yehuda et al., 2000).

Depression and Behavioral Disorders

The relatively high rates of global distress, coupled with the lack of evidence for any one clear psychological diagnosis, has led recent researchers to speculate that more traditional or general measures of psychopathology and well-being may not capture the specific experiences of childhood cancer survivors 22 . One alternative is to view cancer (and, potentially, aspects of the cancer survivorship period) as traumatic events, which may in turn lead to the experience of posttraumatic stress in the survivorship years 22,53,56 .

Role of the Anterior Cingulate Cortex ACC

Every activation study of PTSD subjects finds involvement of the cingulate. However, in some studies there is increased (Bremner, 1999b, 1999a Shin et al., 2001 Lanius et al., 2001) and in others decreased (Sachinvala, 2000) activations. The very process of activating emotion in the unfamiliar context of a laboratory environment might activate the anterior cingulate, including exposure to the stressful laboratory environment itself. Carter et al. (1999) have suggested that ACC activation results in a call for further processing by other brain circuits to address the conflict that has been detected. In most people, automatic mechanisms of emotion regulation are likely invoked to dampen strong emotion that may be activated in the laboratory. The PTSD neuroimaging studies suggest that many traumatized subjects are less capable of activating the ACC in response to emotionally arousing stimuli. In our treatment outcome study of PTSD (Levin et al., 1999), we found increased ACC activation...

Implications For Treatment

For over a century it has been understood that traumatic experiences can leave indelible emotional memories. Contemporary studies of how the amygdala is activated by extreme experiences dovetail with the laboratory observation that emotional memory may be forever (LeDoux et al., 1991). The accumulated body of research suggests that patients with PTSD suffer from impaired cortical control over subcortical areas responsible for learning, habituation, and stimulus discrimination. Hence, current thinking is that indelible subcortical emotional responses are held in check to varying degrees by cortical and hippocampal activity, and that delayed onset PTSD is the expression of subcortically mediated emotional responses that escape cortical, and possibly hip-pocampal, inhibitory control (van der Kolk and van der Hart, 1991 Pitman et al., 1990 Shalev et al., 1992). The early neuroimaging studies of PTSD showed that, during exposure to a traumatic script, there was decreased Broca's area...

Phase Oriented Treatment

Flooding and exposure are by no means harmless treatment techniques Exposure to information consistent with a traumatic memory can be expected to strengthen anxiety (i.e., sensitize and thereby aggravating PTSD symptomatology). Excessive arousal may make the PTSD patient worse by interfering with the acquisition of new information. When that occurs, the traumatic memories will not be corrected, but merely confirmed Instead of promoting habituation, it may accidentally foster sensitization.

Monoamine and Brain Homeostasis A New Hypothesis in Understanding Psychiatric Disorders

The simplistic monoamine depletion hypothesis as an explanation for major depression or any psychiatric disorder is rapidly undergoing critical re-evaluation and restructuring. Of course, it is illogical to think that one neurotransmitter is responsible for one diagnostic category. In addition, our categorical style of making diagnoses is imperfect. Perhaps major depressive disorder is the end-stage syndrome with a multitude of originating etiologies, both psychological and physiological. In addition, there is overlap, not only in illness comorbidity, but also overlap with one individual illness symptomatology and another based on DSM-IV criteria. A good example is major depressive disorder and post-traumatic stress disorder (PTSD). Both illnesses indeed frequently occur together in the same patient. Even though the criteria may seem to separate these diagnoses, in real clinical practice, it is unusual to make the diagnosis of PTSD in a treatment-seeking patient without also...

Definitions of Trauma

There are many definitions of trauma, however, if it is accepted that it may be considered on a continuum of its severity, the extreme points may be described with a use of a broad and a narrow meaning. An example of the broad meaning is the psychoanalytic definition of trauma, that is presented as the disruption or breakdown that occurs when the psychic apparatus is suddenly presented with stimuli, either from within or from without, that are too powerful to be dealt with or assimilated in the usual way (Moore, Fine, 1990). The very narrow definition was offered in DSM-III-R in the description of post-traumatic stress disorder as an event that is outside the range of usual human experiences and that would be markedly distressing to almost anyone. Understanding the processes underlying mental trauma are a challenge for a community of researchers and clinicians dealing with patients suffering from a wide variety of consequences of different traumas resulting not only in an acute stress...

An Application of the Information Metabolism Model to a Multiaxial Psychotherapeutic Diagnosis Case Study

An approximately 60-year-old man was captured, imprisoned, deprived of any form of maintaining orientation and regularly tortured for several months. When he managed to free himself he was anxious and for several weeks kept avoiding all situations which stipulated leaving a place he considered to be safe for several weeks. This form of anxiety increased to a dysfunctional level as he was faced with unpredicted and unexpected events. However, he adopted relatively well to the trauma, with mild, occasional flashbacks, that did not motivate him to start looking for treatment. Intensive PTSD symptoms did not develop until a year later, right after an arranged by the police, face-to-face recognition of kidnappers, took place. Flashbacks of abduction and tortures became persistent as well as did the nightmares. These symptoms were resistant to pharmacother-apy with sertraline, venlafaxine and hypnotics. As the actual threat held true, for several years he remained in ceaseless contact with...

Virtual Reality Exposure Therapy

VRE has also been adapted for Vietnam combat veterans with posttraumatic stress disorder (PTSD). There are two Virtual Vietnam environments a virtual clearing and a virtual Huey helicopter. The virtual clearing, often referred to as a landing zone, includes several trees and a bunker surrounded by jungle. The virtual Huey helicopter flies over Vietnam terrain, which includes rice paddies, jungle, and a river. Audio effects include the sound of the rotors (blades), gunfire, bombs, engine sounds, radio chatter, and male voices yelling Move out Move out Visual effects include the interior of the helicopter in which the backs of the pilot's and copilot's heads are visible, as well as the instrument control panel, and the view out of the side door, including aerial shots of other helicopters flying past, clouds, and the terrain below. The therapist assists the patient in imaginal exposure to his most traumatic memories while immersed in Vietnam stimuli. Preliminary evidence suggests this...

Basic Models Of The Etiology Of Panic Disorder Neurophysiological Models

Parabrachial Nucleus

An abnormally sensitive fear network may result from an inherited tendency to fearfulness, perhaps a neurocognitive deficit, resulting in abnormal response to or modulation of the fear network. Disruptions of early attachment and traumatic events in childhood and adulthood may lead to persistent changes in the stress system and fear network. Gorman et al. (2000) speculate that a genetically based abnormality in the brain fear network may make the individual more susceptible to the emotional effects of trauma.

Etiological Background of Sexual Dysfunction from a Psychologic Interpersonal Perspective

Precipitating factors are those that initiate or trigger sexual problems. For any one individual it is impossible to predict which factors, under what circumstances, will impair sexual desire or performance. Nonetheless, an individual's vulnerability to a particular set of circumstances can precipitate sexual dysfunction. For instance, traumatic events such as the discovery of a spouse's infidelity may cause one man to lose his sexual desire while another man's desire may increase. While initially a precipitating event may be problematic and distressing, it need not necessarily lead to a diagnosable dysfunction in the long term. Over time however, repetition of such events, especially those that damage self-confidence and self-esteem result in sexual dysfunction, even in reasonably resilient individuals. Examples of such precipitating events include con-flictual separation or divorce, a sudden brush with death through an accident or disease process, or unsatisfying sexual experiences.

Professional Misconceptions Regarding Deception

Some conditions, such as Amnesia, hallucinations, and posttrauma reactions, are easily faked and nearly impossible to prove. Faked Amnesia has been detected with promising degrees of accuracy, hovering at about 75 -85 accuracy. Other conditions can be scrutinized for deception. Claimed hallucinations are hard to disprove, yet base rates for comparison and decision criteria are available to assist the evaluator. Posttraumatic Stress Disorder (PTSD) can be assessed by psychometrics or arousal methods with built-in features to assess deception.

Adult Therapeutic Considerations

Clinical presentations are often dissociative (Leavitt, 1994) and posttraumatic stress disorder symptoms, in addition to cult-related phenomena, bizarre self-abuse, and unremitting eating, sleep, and anxiety disorders (Young & Young, 1997, p. 69). Treatment would thus involve principles and techniques that have been found to be effective with posttraumatic stress disorder and dissociative disorders (Kluft, 1985 Putnam, 1989, 1997 Silberg, 1996 van der Kolk, 1987 van der Kolk, McFarlane, & Weisaeth, 1996 Whitfield, 1995).

Loss of Arousal Regulation

Elementary self-regulation involves an interconnected collection of neural patterns that maintain bodily processes and that represent, moment by moment, the state of the organism (Damasio, 1999). The immediate response to a traumatic experience involves dysregulation of arousal, with (a) exaggerated startle response, (b) over- or under-aroused physiological and emotional responses, (c) difficulty falling or staying asleep, and (d) dysregulation of eating, with lack of attention to needs for food and liquid. In people who develop PTSD, this pattern of disordered arousal persists. Once people develop PTSD, they suffer from a fundamental dysregulation at the brain stem level (Sahar et al., 2001). The regulatory processes of the brainstem involve the reticular activating system, the origin of the sympathetic nervous system, as well as two branches of the parasympathetic system, innervated by the vagus nerve the dorsal vagal system and the ventral vagus (Porges et al., 1996). Activation of...

Monoamine Reuptake Inhibitors

Is produced rapidly in humans, with peak plasma levels of up to 3 times those of bupropion and a half-life of 24 hr. Therefore, orally administered bupropion is likely to lead to significant NE reuptake inhibition and relatively less DA reuptake inhibition. Bupropion increases locomotor activity and causes stereotyped behaviors in laboratory animals. In humans, it can cause restlessness, insomnia, anorexia, and psychosis. Bupropion is structurally related to phenylethylamines and unrelated to the TCAs, SSRIs, or MAOIs. It has no significant potency at binding to any known neurotransmitter receptors. Clinical studies have demonstrated that bupropion is effective in the treatment of major depressive episodes (Depression Guideline Panel, 1993). While early studies suggested that bupropion might be less likely to cause hypomania or mania in bipolar patients, subsequent studies suggested that it can cause mania and psychosis in bipolar patients, especially those with high pretreatment...

Acute Stress Disorder

Whereas PTSD can first be diagnosed 1 month after exposure to a traumatic event, acute stress disorder (ASD) can be diagnosed as soon as 2 days after exposure (ApA, 2000). Similar to PTSD, ASD results from exposure to a traumatic event in which the individual feels threatened by death or serious injury and experiences intense emotions, such as fear, helplessness, or horror. in addition, the individual must experience some dissociative symptoms either during or after the event. Dissociative symptoms include feeling emotionally numb or detached from the situation, feeling in a daze, and having the sense that the experience is somehow unreal or that the experience is not happening (ApA, 2000). Similar to the PTSD diagnosis, ASD also involves reexperiencing, avoidance, and arousal symptoms. The symptoms must cause the individual distress or cause impairment in functioning.

Neuropsychiatric Applications

Emotional dysregulation is especially prominent in Anxiety and Mood Disorders. Patients with various .Anxiety Disorders have been scanned during symptom provocation to elucidate the pathophysiology of anxiety. Metabolic abnormalities in the orbitofrontal cortex, the cingulate, and the caudate nucleus have been noted in Obsessive-Compulsive Disorder (Rauch & Shin, 1997). For other Anxiety Disorders, findings are mixed although the anterior paralimbic cortex and the amygdala region have been implicated, particularly in Posttraumatic Stress Disorder (Rauch & Shin, 1997), and Social Phobia (Tillfors et al., 2001). The amygdala region may be a common site of action for behavioral and pharmacological treatments of Social Phobia (Furmark et al., 2002).

The Primary VersusSecondary Distinction

However, other studies find no definite temporal relationships between the disorders. The Harvard Anxiety Research Project (HARP) recruited 711 patients into a longitudinal outcomes study and identified 181 patients with anxiety disorder who also had a history of a substance use disorder. Subjects whose anxiety disorder had an onset before their substance use disorder (primary anxiety), compared with those whose substance use preceded onset of an anxiety disorder (secondary anxiety), did not have different ages of onset for substance use disorder, nor was there greater likelihood for choosing alcohol for any of the anxiety disorders (14). It was noted that there is a lower risk of alcohol use in the small group of generalized anxiety subjects and a greater risk of opioid use in the small group of posttraumatic stress disorder subjects.

Separation Distressanxiety

Although normative changes in distress to separation find it diminishing around 18 to 24 months of age, instances of continued distress response to separation from mothers have been described in the child clinical literature. These instances were described under the heading of separation anxiety. Freud (1895 1959) first conceived of the concept of anxiety neurosis in 1895 and suggested that anxiety was a symptomatic consequence of a repressed libido. Only later, in 1926, did he begin to take note of separation anxiety. The psychoanalytic perspective viewed separation anxiety as a tendency for adults to experience apprehension after the loss of a significant other (Freud, 1926). Freud's later studies led him to conclude that anxiety was an emotion that resulted from the experience of traumatic events. Since that time, separation anxiety has been studied in a variety of contexts, including the attachment literature. It was not until the 1980s that separation anxiety was considered a...

Other Anxiety Disorders Definitions

The DSM-IV diagnostic system includes the following anxiety disorders separation anxiety disorder, panic disorder, agoraphobia, specific phobias, social phobia, obsessive-compulsive disorder, and generalized anxiety disorders, as well as the previously considered posttraumatic stress disorder and acute stress disorder (see Ref. 164 for review). Separation anxiety disorder is defined by excessive and developmentally inappropriate anxiety about separation from parents or other primary attachment figures. Typically less common in adolescents than younger children, a relationship between separation anxiety disorder and adolescent SUD has not been established. Panic disorder and agoraphobia are rare in adolescent samples. Specific phobias are relatively common but probably not a factor in SUD development. Social phobia is nearly as common in adolescent as in adult samples and may influence SUD development and course. Obsessive-compulsive disorder often begins during adolescence, but a...

Studies of Cerebral Metabolism and Blood Flow in Anxiety Disorders

Relatively few imaging studies have investigated specific phobias. Most have employed PET imaging. While one study failed to demonstrate changes in rCBF (Mountz et al., 1989), results from others suggested activation of anterior-paralimbic regions (Rauch et al., 1995a) and sensory cortex (Fredrikson et al., 1995 Wik et al., 1993) corresponding to stimulus inflow associated with a symptomatic state. Although such results are consistent with a hypersensitive system for assessment of or response to specific threat-related cues, they do not provide clear anatomic substrates for the pathophysiology of specific phobia. Whereas one SPECT study of patients with social phobia and healthy control subjects found no significant between-group difference during resting conditions (Stein and Leslie, 1996), more recent cognitive activation neuroimaging studies revealed exaggerated respon-sivity of medial temporal lobe structures to human face stimuli (Birbaumer et al.,...

Treatment of Anxiety Disorders

Are also useful for particular anxiety disorders. Anxiolytic medications (especially the benzodiazepines, such as alprazolam and diazepam) are also effective for reducing anxiety, although they are usually prescribed with caution due to the potential for abuse and the difficulty that some people have discontinuing these drugs. All of the anxiety disorders, except perhaps specific phobias, have been shown to improve following treatment with medications.

Demographic Features of the Anxiety Disorders

Anxiety disorders can occur across a wide range of cultures, ages, sexes, and income levels. In most cases, anxiety disorders are more common in women than in men. The more frequent occurrence in women is most pronounced for Panic Disorder with Agoraphobia and certain specific phobias (particularly animals and storms). For other anxiety disorders, such as Social Anxiety Disorder, blood and needle phobias, and Obsessive-Compulsive Disorder (OCD), the differences between men and women are smaller. The typical onset of anxiety disorders varies, with some tending to begin in early childhood (e.g., animal phobias), others beginning, on average, during the teen years (e.g., Social Anxiety Disorder, OCD), and others tending to begin in early adulthood (e.g., Panic Disorder).

Sensory Symptoms or Deficits

The sense of touch can be affected, producing anesthesias, analgesias, or even tactile hallucinations. The distribution of symptoms follows an idiosyncratic pattern that does not reflect neuroanatomical sensory distribution. This gives rise to glove or stocking distribution patterns, which commonly affect either the upper or lower extremities. Hemianesthesias are also seen, with a clear sensory loss that stops in the midline and commonly involves an entire side of the body. A historically notorious but uncommon presentation in modern times is devil's patches, which consists of idiosyncratic areas of sensory loss, usually around the genitals. In the days of witch hunts, these were considered a demonic sign and used as proof of the victims' pact with the devil. This symptom may be associated with traumatic events such as accidents or sexual abuse.

Comorbidity of Diagnoses

There is substantial overlap among disorders in the DSM-IV. With others, Klein and Riso (1993) have asked whether these disorders represent discrete, natural classes or artificial categories created by the establishment of arbitrary cutoffs on a continuum. In a report from the National Co-morbidity Survey (NCS), Blazer and his colleagues (Blazer, Kessler, McGonagle, & Swartz, 1994) confirmed the high rates of co-occurrence between major depression and a range of other psychiatric disorders. Kessler and colleagues (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), in a second NCS article, reported that Posttraumatic Stress Disorder is strongly comorbid with other lifetime DSM-III-R disorders in both men and women, especially the affective disorders, the Anxiety Disorders, and the Substance Use Disorders. Magee and his colleagues (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996) report that lifetime phobias are highly comorbid with each other, with other Anxiety Disorders,...

The Categorical Versus Dimensional Debate

C., McGonagle, K. A., & Swartz, M. S. (1994). The prevalence and distribution of major depression in a national community sample The National Comorbidity Survey. American Journal of Psychiatry, 151, 979-986. Caplan, P. J. (1991). How do they decide who is normal The bizarre, but true, tale of the DSM process. Canadian Psychology, 32, 162-170. Feighner, J. R., Robins, E., Guze, S. B., Woodruff, R. A., Winokur, G., & Munoz, R. (1972). Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57-63. Guze, S. B. (1995). Review of American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Journal of Psychiatry, 152, 1228. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 10481060.

Lessons From Neuroimaging Symptom Provocation Studies

Explore the pathogenesis and pathophysiology of PTSD. Structural abnormalities in PTSD found with MRI include nonspecific white matter lesions and decreased hip-pocampal volume. These abnormalities may reflect pretrauma vulnerability to develop PTSD or they may be a consequence of traumatic exposure, PTSD, and or PTSD sequelae. Rauch, van der Kolk, and colleagues conducted the first PET scan study of patients with PTSD (Rauch et al., 1996). When PTSD subjects were exposed to vivid, detailed narratives of their own traumatic experiences, they demonstrated increased metabolic activity only in the right hemisphere, specifically, in the areas that are most associated with emotional appraisal the amygdala, insula, and the medial temporal lobe. During exposure to their traumatic scripts, there was a significant decrease in activation of the left inferior frontal area Broca's area, which is responsible for motor speech. Most neuroimaging studies have found activation of the cingulate cortex...


Systematic diagnostic interviewing thus provides a more comprehensive assessment than the typical clinical procedures and has been advocated for clinical evaluations (186). In adolescents suspected as having substance abuse or dependence, the following other mental disorders should be specifically evaluated ADHD, ODD, CD, major depression, and PTSD. A follow-up assessment after an abstinent period of 4 weeks further refines the psychopathology assessment. In addition to evaluating a limited observation period for immediate clinical decisions, assessing the prior life course of substance use disorders may also be instructive (e.g., Ref. 188).


There has long been an interest in the relationship between trauma exposure and nightmares (Freud, 1920 1953 Kardiner & Spiegel, 1947 Horowitz, 1976 Brett & Ostroff, 1985 Ross, Ball, Sullivan, & Caroff, 1989). Subjectively, the experience of the nightmare feels as distressing as a traumatic experience during waking life. The nightmare is associated with the full sensory experience of an autonomic fear response. When nightmares occur during rapid eye movement sleep, a sleep stage in which skeletal muscles are atonic, the sufferer may experience a sense of paralysis and an inability to escape. Hartmann, in his studies of frequent nightmare sufferers, found that adult exposure to violent assault increased nightmare frequency, though he was not able to find a history of early childhood trauma (1984). Kales et al. (1980) also found that the onset of nightmares was preceded by major life events. The National Comorbidity Survey reports a lifetime prevalence of Post-Traumatic Stress...

Concluding Remarks

The relationship between trauma exposure and the development of PTSD is influenced by numerous psychosocial risk factors and individual difference variables. Psychosocial risk factors for PTSD include family history of psychiatric illness, childhood trauma or behavior problems, the presence of psychiatric symptoms prior to the trauma, inadequate social support, and an overreliance on maladap-tive coping strategies. individual difference factors also play a role in the etiology of the disorder. For example, the rate of PTSD in women, after controlling for trauma exposure, is approximately twice as high as the rate for men. in addition, personality traits associated with introversion and Neuroticism have also been identified as liabilities for PTSD, whereas characteristics such as Hardiness appear to represent resilience factors.

Background Issues

The biology of routine stress responses and the biology of trauma are fundamentally different Stress causes a cascade of biological and physiological changes that return to normal after the stress is gone or after the organism has established a new homeostasis. In contrast, in PTSD, the biological alterations persist well after the stressor itself has disappeared. The fundamental problem in PTSD is a fixation of the trauma (Janet, 1889 van der Kolk, 1985 Yehuda, 2002). Thus, the critical issue in understanding PTSD is What keeps the organism from maintaining its homeostasis and returning to a nontraumatic state, and what causes these regulatory processes to break down Exposure to events that overwhelm the organism's coping mechanisms can damage the self-regulatory systems necessary to restore the organism to its previous state because of alterations in a variety of filtering systems in the central nervous system (CNS) that help distinguish relevant from irrelevant stimuli. As a...


Traumatic events are very common in most societies, though prevalence has been best studied in industrialized societies, particularly in the United States. Kessler et al. (1995) found that in the United States at least 15 percent of the population reports having been molested, physically attacked, raped, or been involved in combat. Each year, about 3 million children in the United States are reported for neglect and or abuse to child protective services, with more than half of these cases later substantiated. The vast majority of the abuse and neglect found in children occurs at the hands of their primary caregivers and people they know Four out of five assaults on children are at the hands of their own parents. For women and children, but not for men, trauma that results from violence within intimate relationships is a much more serious problem than traumatic events inflicted by strangers or accidents. Half of all victims of violence in the United States are under age 25 29 percent...


When people are faced with a life-threatening experience, they focus on survival and self-protection. When their usual coping systems fail, they tend to turn to their environment to supply the resources they lack themselves. The quantity and quality of coping resources available depends on the maturity of the nervous system, as well as prior experience and training. Children and exhausted adults are more prone to develop lasting trauma symptomatology than youngsters who live in a protective family, or adults who are well prepared (such as physicians, fire fighters or police personnel). In the immediate aftermath of a traumatic event, victims may respond with a mixture of numbness, withdrawal, confusion, shock, and speechless terror. Some cope by taking action, while others dissociate. Neither response predictably prevents or fosters the subsequent development of PTSD, though being able to maintain an internal locus of control, and utilizing problem-focused coping significantly reduces...


One of the cornerstones of psychoanalytic theory and therapy is the psychological defense mechanism that protects a person from unwanted or unbearable feelings, impulses, or memories. Throughout his life Sigmund Freud, the founder of psychoanalysis, claimed that the purpose of psychoanalytic therapy was to lift the repression that excluded unacceptable mental contents from awareness and to make the unconscious conscious. In 1893 he and his collaborator Josef Breuer argued that repression operated on memories of traumatic events and that allowing these memories back into consciousness, together with the emotion that originally accompanied them, could bring about a permanent cure for hysteria. In 1896 Freud adapted this idea and claimed a unique role for the repression of memories of early sexual traumas. By the beginning of the new century he had already abandoned this stance in favour of the position which was to become part of mainstream psycho

Amygdala Effects

It is hardly surprising that many (though not all) neuroimaging studies of PTSD find increased amygdala activation in response to traumatic reminders. A large body of animal research, mostly in rodents, has established the importance of the amygdala for emotional processes (Cahill and McGaugh, 1998 LeDoux, 1996). The amygdala establishes the initial interpretation of the nature of a particular stress and initiates the process of activating neurochemical and neuroanatomical fear circuitries (LeDoux, 1992). The time frame for this response is several milliseconds. In this very short time, projections from the amygdala to the reticularis pontis caudalis potentiate the startle responses and initiate defensive behaviors that do not require direct action of the sympathetic nervous system. Projections from the amygdala to the lateral hypothalamus and then to the rostral ventral medulla initiate sympathetic nervous system (and catecholamine) responses. One of the most immediate responses to...

Posttraumatic Stress

Likewise, survivorship can offer its own set of traumatic events. Just when survivors are reaching a stage of development at which they are becoming more independent, they may be faced with significant late effects - such as cardiovascular disease, infertility or cognitive disabilities - that limit or otherwise affect the life choices available to them. Further, it is not uncommon for survivors to know fellow survivors who have died of a recurrence or medical late effect. Posttraumatic stress reactions to these distressing events can begin soon after the initial traumatic event and continue for many years. Three kinds of posttraumatic stress symptoms may emerge persistent re-experiencing of the traumatic parts of cancer survivorship (including intrusive thoughts, nightmares or strong negative feelings triggered by reminders), actual or considered avoidance of cancer-or survivorship-related situations and strong physiological responses when reminded about cancer or survivorship 2,29 ....

Frontal Cortex

In recent years, neuropsychological investigations of PTSD have begun to shed light on cognitive control deficits in PTSD, and cognitive neuroscience studies have suggested the neural bases of these deficits. For example, using an array of attention and memory tests, Vasterling (1998) found a pattern of generalized disinhibition in cognitive and behavioral domains among combat veterans with PTSD compared to combat veterans without PTSD. Work in rats and monkeys in a variety of neuroscience laboratories indicates that stress exposure impairs cognitive functions dependent on prefrontal structures. Arnsten et al. (1991) used repetitive transcranial magnetic stimulation (rTMS) The prefrontal structures implicated in PTSD include the left inferior prefrontal cortex, or Broca's area, and the dorsolateral prefrontal cortex. Decreased activation in Broca's area in response to script-driven imagery or remembering was found in the first neuroimaging study of PTSD (Rauch et al., 1996) and has...


The modern rediscovery of trauma as an etiological factor in mental disorders goes back only to about 1980. During this time there has been an explosion of knowledge about how experience shapes the central nervous system and the formation of the self. Developments in the neurosciences have started to make significant contributions to our understanding of how the brain is shaped by experience, and how life itself continues to transform the ways biology is organized. The study of trauma has been one of the most fertile areas within the disciplines of psychiatry and psychology in helping to develop a deeper understanding of the interrelationship between emotional, cognitive, social, and biological forces that shape human development. Starting with posttraumatic stress disorder (PTSD) in adults, but expanding into early attachment and coping with overwhelming experiences in childhood, our field has discovered how certain experiences can set psychological expectations and biological...

Stress Consequences

In addition to the immediate effects, stressful events may proactively influence the response to later stressor experiences. It seems that stressors may result in the sensitization of processes that promote central neurochemical functioning so that reexposure to the same stressor (and even to alternate stressors) at a later time may result in the neurochemical changes occurring more readily. Thus, such sensitization processes may contribute to the induction of stressor-related illnesses even at lengthy intervals following a trauma and may be responsible for the high rates of relapse associated with illnesses such as depression. It is important to note that in addition to simple sensitization effects, cross-sensitization has been observed so that stressors increase the response to drugs such as amphetamine and cocaine. Likewise, it has been shown that the administration of cytokines, signaling molecules of the immune system, may result in a sensitization effect so that the response is...

Trauma Definition

Trauma can be conceptualized as both an event and a reaction. A traumatic event is one in which an individual experiences actual or threatened serious injury or death (American Psychiatric Association ApA , 2000). Examples of traumatic events include military combat, sexual assaults (e.g., rape or child sexual abuse), interpersonal physical assaults (e.g., a mugging), natural or manmade disasters, terrorist attacks, and motor vehicle accidents (ApA, 2000 Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).

Other Symptoms

Other disorders can cooccur with PTSD, ASD, or adjustment disorder. One of the most commonly cooccurring disorders is depression. In a national survey of more than 5,000 individuals, nearly half of individuals meeting criteria for PTSD also met criteria for depression (Kessler et al., 1995). PTSD has also been associated with higher rates of substance use, especially among war veterans (Kulka et al., 1990). In addition, PTSD has been associated with other anxiety disorders, such as panic disorder, social phobia, and generalized anxiety disorder (Kessler et al., 1995). In addition to other diagnoses, there are a number of responses that are often associated with PTSD. For example, individuals with PTSD often experience dissociative symptoms during or after the traumatic event (Griffin, Resick, & Mechanic, 1997 van der Kolk & Fisler, 1995). Deficits in memory specific to the trauma, as well as deficits in short-term memory in general, have also been noted (Bremner et al., 1993...

Risk Factors

It is important to note that not all individuals who experience a traumatic event develop a psychological disorder. For example, in a prospective study of rape victims, 94 of the participants endorsed enough symptoms to be diagnosed with PTSD one week after the rape (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). However, when assessed 3 months after the rape, only 47 met PTSD criteria (Rothbaum et al., 1992). These statistics suggest that most rape victims experience intense PTSD symptoms immediately following the rape. Over half of the victims naturally recover from these symptoms over time. The others, however, remain symptomatic. Researchers have begun to identify risk factors for developing a psychological disorder after exposure to trauma. Gender seems to be one such factor research suggests that more women than men develop PTSD (Brewin, Andrews, & Valentine, 2000 Kessler et al., 1995). Individuals lacking social support are also at greater risk for developing a...


Ogy, recognizing that hypnotic processes are normal and yet can be mobilized to resolve an unconscious conflict. This led to the theory of conservation of psychic energy, which proposed that emotion that could not be expressed otherwise would be converted into physical symptoms. In other words, the affect associated with traumatic events, which was not expressed because of the moral or ethical meaning to the patient, could be repressed and converted into a somatic hysterical symptom that was symbolic, in some way, of the original emotional trauma. The purpose of therapy was to uncover the traumatic memories and associated affects (abreaction) so that emotional catharsis could occur, resulting in symptom resolution.


Conversion disorder commonly occurs in association with other psychiatric and medical disorders (Bowman 1993). Psychiatric disorders commonly seen in patients with conversion disorder are major depression, somatization disorder (Briquet's syndrome), anxiety disorders, alcohol abuse, dissociative disorders, depersonalization disorder, and personality disorders. The most common lifetime psychiatric diagnosis in patients with acute conversion symptoms is major depression (about 85 ) (Roy 1980 see also Zeigler et al. 1960). In a study of 26 patients with pseudoseizure, Bowman (1993) found a high rate of current psychiatric disorders and history of trauma, with a history of sexual abuse or rape in 77 and a history of physical abuse in 70 . Eighty-five percent had depressive disorders, 85 had dissociative disorders, 33 had posttraumatic stress disorder, and 11 had panic attacks. The most common personality disorders in women with conversion disorder are histrionic and dependent personality...

Future Directions

Considerable work needs to be done to determine the extent to which anxiety disorders other than PTSD are relevant for adolescent SUD etiology and treatment. Clinical and community studies have indicated that anxiety syndromes lead to SUD and are caused by substance consumption. Progress in this area may be inhibited by the tendency to hypothesize that only one or the other causal direction is true. In fact, a more complex model may be more valid in which SUD and psychopathology contribute to a positive-feedback loop. This loop may have a neurobiological basis, as alcohol consumption has been found to be associated with diminished benzo-diazepine receptor binding (181,182). The literature to date suggests that several complexities need to be considered in future studies, including the following 1) each anxiety disorder may have a unique relationship with SUD 2) SUD involving specific substances may have unique relationships with each anxiety disorder and 3) different relationships may...


Trauma is a specific term referring to unusual psychological and physiological reactions to major losses, such as the death of close others. Traumatic reactions may be so severe as to constitute Posttraumatic Stress Disorder (PTSD), which is a particular diagnostic category in psychology and psychiatry. The field that now is called traumatology began with an ancient Egyptian physician's reports of hysterical reactions that were published in 1900 b.c. in Kunyus Papyrus (quoted in Figley, 1993, p. 3) and that became one of the first medical texts. Traumatology may be defined as the investigation and application of knowledge about the immediate and long-term psychosocial consequences of highly stressful events and the factors that affect those consequences. This field evolved mainly within the last 2 decades, with foci both on research and therapy and application. The onslaught of studies of PTSD after the Vietnam War was a major factor in contributing to development and refinements of...


Overall, survivors of childhood cancer report doing very well and demonstrate low rates of traditional psychological issues. Though most do well, a significant minority may experience PTSD, and most survivors and their family members experience at least some symptoms of posttraumatic stress related to cancer, treatment or survivorship experiences. The large majority of these reactions - although they can pose significant impediments to individual and family development - are normal reactions to the unusual stress of childhood cancer that are likely to emerge unpredictably and to wax and wane over the course of time. Social and relationship differences may also affect childhood cancer survivors, though it is unclear whether these differences contribute to ongoing distress. It is essential during any comprehensive follow-up care program that there be a sensitive assessment of these issues and that the development of interventions to combat psychological late effects be part of ongoing...

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