Therapist's Guide to Posttraumatic Stress Disorder Intervention

353 Pages·2009·12.918 MB·English

by  Sharon L. Johnson

Academic Press is an imprint of Elsevier
32 Jamestown Road, London NW1 7BY, UK
30 Corporate Drive, Suite 400, Burlington, MA 01803, USA
525 B Street, Suite 1900, San Diego, CA 92101-4495, USA
First edition 2009
Copyright © 2009, Elsevier Inc. All rights reserved
No part of this publication may be reproduced, stored in a retrieval system
or transmitted in any form or by any means electronic, mechanical, photocopying,
recording or otherwise without the prior written permission of the publisher
Permissions may be sought directly from Elsevier’s Science & Technology Rights
Department in Oxford, UK: phone (44) (0) 1865 843830; fax (44) (0) 1865 853333;
email: [email protected]. Alternatively visit the Science and Technology Books website at
www.elsevierdirect.com/rights for further information
Notice
No responsibility is assumed by the publisher for any injury and/or damage to persons
or property as a matter of products liability, negligence or otherwise, or from any use
or operation of any methods, products, instructions or ideas contained in the material
herein. Because of rapid advances in the medical sciences, in particular, independent
verification of diagnoses and drug dosages should be made
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress
ISBN: 978-0-12-374851-5
For information on all Academic Press publications
visit our website at elsevierdirect.com
Typeset by Macmillan Publishing Solutions
(www.macmillansolutions.com)
Printed and bound in the United States of America
09 10 11 12 13 11 10 9 8 7 6 5 4 3 2 1
IntroductIon
THIS book has been written to serve as an essential resource in trauma intervention for
therapists who want to enhance their skill in working with those who have posttraumatic
stress disorder (PTSD). It also provides a review of the vast spectrum of associated theories
and pertinent information. PTSD remains a controversial diagnosis, with numerous theo-
retical underpinnings attached. Even the American Psychiatric Association’s Darrel Regier,
MD, MPH, executive director for research and education, states, “It is very important to
have a better paradigm than what we have been using to look at somatic presentations of
mental disorders, and the relationship of disorders in other organ systems.” This statement
contributed to the author’s belief that while somatic treatment may appear to be in the
realm of “feel good therapy” its tenets offer useful information regarding the understanding
of the patient’s experience and belief system. However, it does not change the current stand-
ard of care for evidenced-based treatment: the first-line treatment for PTSD is cognitive
behavioral therapy and psychopharmacology. It should also be recognized that gender and
cultural issues play a role in the connection between mental and physical health in associa-
tion with physiological characteristics, socio-cultural influences and personal perspectives.
This book is divided into three parts: Biopsychosocial Aspects and Diagnosis of PTSD,
Treatment, and Skill Building. Most books on the topic cover one perspective of theory,
knowledge, or treatment of PTSD, or several valuable pieces of information which the
therapist (providing direct services) is able to utilize in their daily practice. This text is a
transtheoretical review with a cognitive behavioral focus that incorporates physiology,
body-oriented and emotional/relational theoretical perspectives and interventions. The
reviews center on empirically based research and well-known national and international
theorists, researchers, and clinicians. The goal for the expansion of information and encom-
passing renowned leaders in the field was to broaden the perspective of PTSD, which bet-
ter suits the rich diagnostic complexities of the disorder instead of narrowing the field of
understanding and interventions. It is acknowledged that the standard of care for PTSD
will continue to change as scientific information and advances clarify all aspects of the dis-
order. This research will continue to result in an evolution of the diagnosis and treatment
of PTSD. However, at this time, all of the major guidelines consistently identify cognitive
behavioral therapy and pharmacologic intervention as first-line treatments, in conjunction
with numerous beneficial second-line treatments.
xi
This is a useful text for any therapist and was developed with consideration of the high
level of demand placed upon those practicing to deliver effective treatment using outcome-
oriented interventions. Not only has managed care significantly impacted the time frame
of therapy, but consumers also demonstrate an elevated level of expectation for evidence
of relief and recovery. On the positive side, the result has been increased collaboration in
developing the treatment plan and increased responsibility on both sides of the partnership
to fulfill the obligations laid down in the treatment plan. This requires that the treatment
plan be clear, concise, and time-effective and that it demonstrates the medical necessity for
treatment. Again, the premise is to evaluate the current situation to determine what is pres-
ently causing distress and to intervene in a manner which alleviates distress and improves
coping.
For the most appropriate and effective utilization of the information contained in the
Therapist’s Guide, therapists should be professionally trained and licensed in their state or
country. Typically training includes a graduate level degree, a clinical internship or its equiv-
alent, and past supervision in the specific technique or approach employed. Any profes-
sional provider of interventions and/or treatment to individuals following the experience of
trauma should be well-trained, experienced practitioners. The user of this book is respon-
sible to consider their own expertise in providing services. In addition, to effectively access
the information in this text it is recommended that the therapist familiarize themselves with
the contents so that they are easily accessed.
Whether it is a traditional, terminal, or professional mental health program under con-
sideration, there is a need to include education on trauma response and treatment skills
across all mental health disciplines in accordance with the therapist’s ethics, education, and
training. This training should incorporate knowledge, supervision, and experience in the
different types of trauma, trauma responses, and interventions (sexual/physical/emotional
abuse, critical incident, and mass disaster which includes natural disaster and terrorist
attack). This diagnosis is particularly vulnerable to more damage being done to the seeker
of treatment if the therapist lacks necessary education, training and expertise.
The first section of the book covers a significant amount of distilled information in an
effort to present the therapist with a user-friendly review and overview of PTS, diagnos-
tic criteria, comorbidity, functional impairment, neurobiology, and accurate diagnosing of
PTSD. It highlights the difficulties experienced in the clinical setting, which often lead to the
diagnosis of PTSD being overlooked and how to take a more comprehensive approach to
accurately determine this complex diagnosis, which often presents with diagnostic comor-
bidity. It discusses the range of PTS-related diagnoses for the purpose of conceptual under-
standing, but the focus of this text is on PTSD.
The second section of the book covers the transtheoretical treatment options and treat-
ment planning. As previously stated, the aim was to include theoretical information from
well-known national and international theorists, researchers, and clinicians because the
information is valuable and allows for flexibility for individualized intervention even within
the frame of cognitive behavioral treatment. The physiological experience is so fundamen-
tal to the diagnosis of PTSD it is not reasonable to disregard information because it is not
within the parameters of traditional cognitive behavioral treatment. To do so, would be
antithetical to the needs of patient characteristic individuality, and the need to meet the
patient where they are in symptom presentation, skill level, resources, and belief system.
The sophisticated therapist recognizes much of the information from their own first-hand
clinical experience. It is actually validating to the seasoned therapist to see literature that
addresses the complexity of information provided by those they treat with PTSD. The treat-
ment planning segment is drawn from the central areas of PTSD diagnostic criteria symp-
tomology in the form of goals with associated treatment objectives for accomplishing those
goals. Cognitive behavioral interventions offer appropriate structure and are excellent for
achieving stabilization, improving coping, and facilitating change.
The third section of the book offers skill building resources for increasing competence.
The information in this section can be used adjunctively during therapy, as education,
and/or homework. The information in this section and its presentation are designed to
be supportive of a cognitive behavioral therapeutic frame. This allows for the goals and
xii
   Introduction
objectives to be easily understood and engaged. The more those presenting for treatment
can be helped to understand how they have been affected by what has happened to them
and the role they play in sustaining patterns or problems, as well as identifying recovery
resources, the more they can be motivated to make the necessary changes via a variety of
pathways offered by knowledge and skills development. These recovery efforts have a self-
reinforcing quality. Again, even though the focus is on a cognitive behavioral frame it does
not exclude the utility of deep personal searching associated with psychodynamic theory or
dealing with physiological symptoms medically or by the use of somatic theory.
The patient offers the information about their experience, how they have been impacted,
and their level of coping. In their effort to seek support and effective interventions to allevi-
ate their distress they are depending on the therapist to be thorough, skilled and flexible in
developing a treatment plan designed to meet them where they are and to use well-chosen
skills necessary for facilitating desired change and eliminating or alleviating their experience
of distress. This is the foundation of the individualized treatment plan.
xiii
Introduction
I
P
art
Biopsychosocial Aspects and
Diagnosis of PTSD
1
Chapter
Assessing and Diagnosing Posttraumatic
Stress Disorder
The National Institute of Mental Health (2008) states that 2.5 million people are hospitalized
each year having sustained injuries during a traumatic event. As the literature is reviewed,
however, it can be seen that most research has been focused on combat veterans (predom-
inantly Vietnam and the Middle East) and female adult survivors of sexual abuse/assault.
When clinicians engage with those who have been exposed to trauma, they are challenged to
differentiate posttraumatic stress disorder (PTSD) from other clinical problems. Sometimes
symptom presentation is simple (such as depression and/or anxiety), in other instances symp-
tom presentation demonstrates multiple layers of comorbidity.
PTSD is a complex and often chronic disorder that has been found to be comorbid with
numerous other disorders. While exposure to a traumatic event appears common, only a
fraction of those exposed to trauma develop posttraumatic stress disorder. The symptoms of
PTSD are indicative of a disturbance of the normal capacity to resolve cognitive and emotional
responses to traumatic events (Yehuda and McFarlane, 1995). It is a disorder that involves
a traumatic stressor, intrusive recollections, avoidant symptoms, and hyperarousal. Earlier
diagnostic criteria set acute stress disorder (ASD) and PTSD apart from all other psychiatric
diagnoses by including the requirement that one of the factors should be outside of the indi-
vidual: “a traumatic stressor.” Some patients diagnosed with chronic PTSD develop pervasive
and persistent incapacitating mental illness which can negatively impact all areas of psychoso-
cial functioning (marital/family, social, work/school). Van der Kolk (1996) highlights the most
basic premise of the experience, stating that beliefs and cognitions give meaning to the emo-
tion brought on by trauma. These thoughts activate the amygdala and trigger the emotions
which, for many, become the central challenge of moving forward from their experience of a
traumatic event. One of the potential consequences of trauma is that emotional memories of
trauma get incompletely processed and are constantly being reactivated by triggers.
Therapist’s Guide to Posttraumatic Stress Disorder Intervention Copyright © 2009, Elsevier Inc.
All rights reserved

While the effects of psychological trauma have been acknowledged throughout history by
mental health and medical professionals, PTSD was first suggested as a diagnostic category
in the development of the third edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-III) in 1980. It was an extremely controversial diagnostic category at the
time due to the required criterion for an external traumatic event. Nevertheless, the high
rate of psychiatric casualties among Vietnam veterans inundating US Department of Veterans
Affairs facilities helped to establish PTSD as a legitimate diagnosis. The diagnostic struggle
continues, however, as researchers try to determine whether symptoms emerge only in rela-
tion to the trauma or are suggestive of a significant underlying psychiatric disorder(s).
Yehuda et al. (1998) emphasized the evidence of an abnormal acute stress response of a
biological nature in those with PTSD. Many feel that the substantial experiential aspect of
physiological effects have not been adequately considered diagnostically, which has limited
and/or negatively impacted treatment as well as diagnosis. Darrel Regier, MD, MPH, execu-
tive director of the American Psychiatric Institute for Research and Education, states “It’s
very important to have a better paradigm than what we’ve been using to look at somatic
presentations of mental disorders, and the relationship to disorders in other organ systems”
(Regier, 2007). This illustrates the limitations of the tradition nomenclature of diagnostic
criteria, highlighting the need to explore physical–mental associations, along with lifespan,
gender and cultural issues.
Another view by Keane (2006) is that PTSD does not and should not describe all of the
possible symptoms of the disorder, and therefore there is no need to expand the nomencla-
ture to include complex PTSD.
Trauma is the consequence of exposure to an overwhelming and inescapable event which
overcomes a person’s coping ability, thus encapsulating the interaction between the individ-
ual and the traumatic event. In other words, no two people exposed to the same event will
react in the same manner. The person’s ability to cope with the traumatic exposure will be
associated with factors, such as (1) their belief system, (2) prior experience(s) of trauma, (3)
chronic stressful experiences, (4) level of support, (5) perception of their ability to cope with
the event, (6) internal resources (coping mechanisms etc.), (7) genetic predisposition, and (8)
other stressors in their life at the time of the event.
PTSD is a multifaceted and complex disorder which challenges the clinician in making an
accurate diagnosis. Bearing in mind that there is significant controversy about the criteria
written in the diagnostic nomenclature, this review will begin with the diagnostic criteria set
by the diagnostic manual and expand from there to encompass the conceptual and practical
challenges in evaluating trauma exposure. Currently, the fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR) foundation for the PTSD syndrome
includes 17 symptoms within three symptom clusters:
1. Re-experiencing the trauma
2. Avoidance and numbing
3. Hyperarousal.
The first step in assessing trauma is to establish and identify exposure to an extreme stres-
sor, Criterion A in the DSM diagnostic criteria. An extreme stressor is identified as having
three elements:
l The type of exposure (directly experienced, witnessed, informed indirectly)
l Distinguishing traumatic stress from ordinary stress, i.e. the event presents a
threat to life, serious injury, or threat of physical integrity to self or others.
l The event triggers an intense emotional response of fear, horror, or helplessness.
As can be seen, the subjectivity of this criterion is the basis of the controversy, either viewed
as personally restrictive (what is traumatic from one individual to another) or that the crite-
rion is too broad, which allows too many stressors to be identified as traumatic. Whatever the

1 Assessing and Diagnosing Posttraumatic Stress Disorder
view, the gatekeeper function of Criterion A is important for setting a parameter or threshold
of what is identified as an extreme stressor warranting the diagnosis of PTSD.
Once it has been determined that a patient has experienced exposure to trauma, the thera-
pist can consider, based upon symptom presentation, which diagnostic criteria are matched.
The continuum of diagnoses associated with exposure to a trauma are commensurate with
the range of emotional and psychological reactions experienced and are shown diagrammati-
cally in Figure 1.1.
The next step in assessing for PTSD is to review the constellation of symptoms used to
determine if the patient has the necessary number of symptoms in each symptom category to
differentiate a diagnosis from diagnostic features (fewer symptoms than warranted for a diag-
nosis) from a diagnosis of PTSD. There are several noted difficulties regarding this mission:
l The large number of symptoms that represent both overt and covert manifestations.
A diagnosis requires:
(a) at least 1 of 5 re-experiencing symptoms;
(b) at least 3 of 7 avoidance and numbing symptoms; and
(c) at least 2 of 5 hyperarousal symptoms.
l Some symptoms are vague in definition, leading to a lack of consensus as to what
is exactly meant by the terminology. This leads to poor interpretation and signifi-
cant variance in accuracy of symptom determination.
l Symptom overlap between clusters, which can lead to what is called “double cod-
ing” of symptoms, meaning that they are given diagnostic credit for essentially
the same symptom in different symptom categories.
l Negative symptoms (such as emotional numbing or loss of interest) may be
difficult to assess because the patient is focused on positive symptoms with
notable associated distress.
l Are the presented symptoms within the normal range of reaction to such an
experience or is the symptom representative of a pathological or clinically
significant problem?
Traumatic
experience
Acute stress reactions
ASD
PTSD Associated problems
- Substance abuse/dependence
- Physical problems
- Relationship problems
- Vocational problems
Complex PTSD Reaction to a combination of
traumatic events and
chronic stress (a diagnostic
term used by some noted
leaders in the field of PTSD
which has not been accepted
as a different diagnosis by
the DSM)
Figure 1.1 The range of emotional and psychological reactions following a traumatic experience.

Assessing and Diagnosing Posttraumatic Stress Disorder
l Patients presenting for assessment or treatment following a current trauma
exposure that present with prior trauma exposure and/or previous posttraumatic
stress symptoms must present a clear and distinct change from their previous
level of functioning.
l Multiple practitioners are often involved. Often the patient may be referred
from their primary care physician for depression or anxiety with an associated
misinterpretation of origin or history of symptoms. This may result in an incor-
rect diagnosis.
With this brief review of potential diagnostic difficulties, one can see why developing
diagnostic criteria for PTSD has been so arduous and factious. Just investigating one symp-
tom can demonstrate the numerous questions posed that are often not easy to define by
an accurate qualitative or quantitative answer. For example, Weathers et al. (2004) makes
an excellent point in questioning the origin of a symptom such as amnesia in assessing for
PTSD. If the patient is not able to recall aspects of their experience it may be difficult to
determine whether it is the result of intense fear and associated avoidance, having been
unconscious during part of the event, or poor memory which has another foundation (med-
ical, function of time, etc.).
Symptom cluSterS and additional diagnoStic criteria
In addition to Criterion A (defining the trauma exposure) there are five other criteria
(B through F) and additional specifiers.
The Diagnostic Manual, DSM-IV-TR, describes the development of characteristic symp-
toms following exposure to an extreme traumatic stressor, through either direct experience,
witnessing, or knowledge of an event that involved actual or perceived threat to life or phys-
ical integrity of self or others. In such a situation a person’s response involves intense fear,
helplessness, and/or horror. The symptoms, which cause significant distress or impairment
in social or occupational functioning, must be present for at least one month. The diagnostic
criteria or symptoms consist of three clusters (B, C, D):
Category B: Persistent re-exPerienCing of the
traumatiC event (at least one symPtom)
1. Recurrent and distressing recollection of the events (images, thoughts,
impressions)
2. Recurrent distressing dreams of the event
3. Acting or feeling as if the traumatic event were recurring
4. Intense psychological distress at exposure to internal or external cues that sym-
bolize or resemble an aspect of the traumatic event
5. Physiological reactivity on exposure to internal or external cues.
The patient experiences flashbacks, traumatic daydreams, or nightmares in which he or
she relives the trauma as if it were recurring in the present. Intrusive symptoms result from

1 Assessing and Diagnosing Posttraumatic Stress Disorder