Structure of Post-traumatic Stress Disorder (PTSD)
The current diagnostic criteria for post-traumatic stress disorder (PTSD) require presenting symptoms from each of three clusters: re-experiencing, avoidance and hyperarousal (American Psychiatric Association [APA], 2000). These clusters were developed based on clinical experience rather than empirical research (Olff, Sijbrandij, Opmeer, Carlier & Gersons, 2009), and since the initial formalization of these clusters a significant amount of research has been conducted to investigate the accuracy and appropriateness of this diagnostic structure.
In addition to the general desire to better understand PTSD, several concerns have driven this ongoing research. The introduction of the diagnosis of acute stress disorder (ASD; APA, 1994) with little empirical support raised questions as to the validity of ASD and the justifications for differentiating between ASD and PTSD; the avoidance cluster of PTSD symptoms appears to contain two different constructs – behavioural avoidance of external stimuli, and cognitive or emotional suppression of distressing internal experiences; and the high comorbidity rates and overlap in symptomatology between major depressive disorder (MDD) and PTSD, with no apparent difference in precipitating factors in individuals diagnosed with both disorders (Breslau, Davis, Peterson & Schultz, 2000) suggests that there may be a separate affective factor not represented in the current PTSD diagnostic criteria.
Factor analysis of validated PTSD assessment instruments based on DSM diagnostic criteria support the contention that PTSD is better represented by four symptom clusters (Olff et al., 2009). Although the best descriptions and structure of each of the factors is still under discussion, it appears that the current avoidance and hyperarousal clusters might be better restructured as active avoidance (i.e. behavioural avoidance of external stimuli), dysphoria (comprised of current emotional and cognitive ‘avoidance’ criteria, and the sleep, irritability and concentration factors currently part of the hyperarousal cluster) and hyperarousal (comprised of the remaining hyperarousal symptoms). As well as being based on empirical findings rather than clinical experience or theory, the new dysphoria cluster would also contain those symptoms which overlap with symptoms of depression. This would make differential diagnosis between PTSD and MDD clearer, and allow more appropriate treatment to be chosen for PTSD sufferers whose presenting symptoms are predominantly dysphoric.
Comorbid PTSD and Substance Use Disorders
PTSD can be explained behaviourally by an interaction of classical and operant conditioning. Reminders of the trauma – both external cues and memories – become aversive because of the distressing emotions that they elicit, and behaviours that succeed in temporarily avoiding such reminders are negatively reinforced by reducing the distress (Kohlenberg, Tsai & Kohlenberg, 2006). Consequently, avoidant behaviours not listed as diagnostic criteria for PTSD are often found comorbid with the disorder, including substance use disorder (SUD).
One of the problems with comorbid PTSD and SUD is that exposure therapy to overcome avoidant behaviours is empirically the most effective treatment for PTSD (Ruzek & Rosen, 2009). This exposure is inherently distressing, and can lead to increased avoidance through substance use, which in addition to the problems of substance use also interferes with the exposure treatment itself. In order to overcome this cycle it is often necessary to develop alternatives for coping with distress, which Seeking Safety, a cognitive-behavioural programme, aims to do.
Seeking Safety has been found effective in reducing symptoms of PTSD in pilot studies, and in randomized controlled trials (RCT) comparing it to treatment-as-usual and waiting-list control groups (Hien et al., 2009). In a large-scale, multiple-site RCT using participants representative of treatment in a community setting, Seeking Safety was compared to a psychoeducational attention control group (Women’s Health Education [WHE]), with both found to achieve significant improvement in PTSD symptoms, improvements that were not significantly different from each other (Hien et al., 2009). Seeking Safety showed a slightly more rapid improvement in PTSD symptoms than WHE, but neither programme resulted in a significant improvement in levels of substance use. Although WHE was intended in this trial to be a control group, the improvements exhibited suggest that there is an active element to WHE.
Prior research with active substance users has consistently found that Seeking Safety significantly reduces substance use, an effect that may have been obscured in this trial because the sample also included people who were abstinent at the start of the trial. It is also possible that the improvements in PTSD symptoms found in the WHE group would not have been comparable to Seeking Safety if the participants had not included abstinent individuals.
Family Support in Recovery from PTSD
An individual’s perceived level of social support has been found to be a factor in improving the ability to recover from a traumatic experience and PTSD symptoms (Guay, Billette & Marchand, 2006). This is particularly true of support from immediate family, but at the same time changes in family functioning have been observed when a family member develops PTSD. It has been unclear whether PTSD affects family functioning, or vice versa, or whether there is an interactive relationship between the two.
In a longitudinal study of veterans being treated for chronic PTSD, structural equation modelling supported the hypothesis that family functioning predicted recovery from PTSD, but PTSD did not conversely predict family functioning (Evans, Cowlishaw & Hopwood, 2009). These findings support the idea that treatment for PTSD can be improved by actively involving family members as part of the treatment. However it should be noted that this study focused on chronic rather than acute PTSD, changes may have occurred to family functioning prior to the start of the study, and families that were so negatively impacted by a family member suffering from PTSD that they were unable to remain intact would not have been part of the study.
Critical Incident Stress Debriefing
Critical incident stress debriefing (CISD) has become a standard of care in the immediate aftermath of trauma (Neely & Spitzer, 1997). CISD is intended to be implemented within 72 hours of the trauma, designed for a group format (although it can be used in an individual context), and comprises psychoeducation regarding the effects and symptoms of PTSD, recalling memories of the traumatic event, thoughts about the event, the emotions that it engendered and ‘appropriate referrals’ when needed for further treatment (Devilly, Gist & Cotton, 2006).
CISD was originally introduced more than 25 years ago (Mitchell, 1983) to address growing concern about PTSD and the effects of trauma. Claims of CISD’s effectiveness were based on small-scale and methodologically flawed studies (Devilly et al., 2006). More recent, larger-scale, studies have not only failed to replicate the original positive findings (Wagner, 2005) but some have found iatrogenic effects (Bledsoe, 2003). A recent large-scale (N = 1,004) study of CISD applied to US peacekeeping forces found it to be no more effective than a no-treatment control in addressing PTSD and depressive symptoms, and may actually have increased levels of aggression among participants (Adler et al., 2008).
The only area in which CISD was reportedly more effective was in expressed perception of organizational support, which may have been an effect of cognitive dissonance from participants’ investment of time and effort in the intervention (Adler et al., 2008). The most recent review of preventative interventions for PTSD by the Cochrane Collaboration states that there are no interventions, single or multiple session, suitable for routine use following traumatic exposure, in either military or civilian contexts (Roberts, Kitchiner, Kenardy & Bisson, 2009).
In spite of this, and the fact that 90% of trauma survivors do not develop PTSD (Breslau, 2002), CISD is still advertised as an appropriate universal response following a traumatic event. Many organizations have adopted it not because it is effective, but because it is evidence of doing ‘something’, and therefore a defence in the event of legal action (Devilly et al., 2006). The argument that ‘something is better than nothing’ is not only unsupported by the research, but is contradicted by the aetiology of PTSD. Repeated trauma increases the probability of developing PTSD (Bryant, 2003), and being forced to re-live the trauma before one is ready can effectively repeat the trauma. Furthermore, PTSD can develop from secondary, or vicarious, trauma (Baird & Kracen, 2006). An assumption underlying the group format of CISD is that the participants are normalizing their shared experiences of the traumatic event (Devilly et al., 2006), but it is unlikely that everyone will have witnessed all of the potentially traumatizing elements of an event, and listening to traumatic descriptions that one did not personally witness can have a secondary traumatizing effect in addition to the elements that one did personally witness.
Research indicating that the symptoms of PTSD form four rather than three clusters suggests the diagnostic criteria for PTSD may need to be revised. Even before such a revision is formally made, clinicians can apply the findings of a dysphoric symptom cluster to improve differential diagnosis between PTSD and MDD, and present more appropriate treatment options.
Research and clinical experience both support the contention that when PTSD presents comorbid with SUD the avoidant function of the substance use needs to be addressed to improve the chance that PTSD treatment will be adhered to and ultimately effective. Both Seeking Safety and psychoeducational treatments have been found effective, but it is unclear which elements of the treatments are effective, and which treatment might be most effective for the presenting SUD and PTSD symptomatology of any given client. Further research to understand the effective elements and their most appropriate application is needed.
Social support is a strong predictor of recovery from PTSD, and research supports the contention that, at least for chronic PTSD, family function is predictive of treatment success. If these findings are supported for acute PTSD, they would suggest that enrolling the family in treatment would be an effective adjunct to individual or group therapy. However, even though family support is predictive of PTSD recovery, the family environment can also be a significant factor in the origin and maintenance of PTSD. It would likely be counterproductive, for example, to engage an abusive spouse in treating the PTSD that his or her abusive behaviour is instrumental in creating. There is a need not only for further research to determine the extent and applicability of the research findings but also for careful construction of practice guidelines to ensure clinicians do not inadvertently place abuse victims in a situation where they are even more vulnerable to their abusers.
CISD has become widespread in the belief that it effectively prevents PTSD. Though the evidence is growing that the opposite is true, the practice of ‘defensive psychology’ to avert legal action is still a significant motivator in its continued use. However, research indicating that CISD may be iatrogenic is beginning to exert pressure in the opposite direction, with arguments made in court that systematic use of CISD is itself negligent and grounds for legal action (Devilly et al., 2006). This leaves those in a position of potential legal liability in a quandary, where they may be sued because CISD has been implemented, or because it has not. No routine intervention to prevent PTSD is recommended, and research on targeted interventions is needed (e.g. Schartau, Dalgleish & Dunn, 2009; Shipherd, 2009), not just to relieve this quandary, but for the simple reason that the need to prevent PTSD which CISD was intended to address still exists.
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