Multidimensional assessment of combat-related PTSD: Phenomenological,psychometric, and psychophysiological considerations

The literature on assessment of PTSD in combat veterans is discussed as it relates to several major diagnostic issues. Studies bearing on the validity of the PTSD diagnosis are presented. Additionally, a multidimensional assessment of PTSD is described in detail. The major assessment instruments currently used are discussed and the research supporting the selection of each of the assessment tools is presented.     

Keane PTSD scale: MMPI and MMPI-2 update

This paper addresses questions regarding the use and interpretation of the Keane MMPI PTSD scale. Particular focus is placed on issues to consider when using various versions of the MMPI including Form R, the group form, and the new MMPI-2.     

Validation of the purdue post-traumatic stress scale on a sample of vietnam veterans

The Purdue Post-traumatic Stress Disorder Scale is a 15-item self-report instrument based on the DSM-III diagnostic criteria for post-traumatic stress disorder. This scale is a quick, easily administered, measure of psychological reactions to a traumatic event. The goal of the present report is to validate this instrument for use as a measure of long-lasting combat stress reactions of American Vietnam veterans. The PPS demonstrated a high degree of internal consistency with a Cronbach's coefficient alpha of 0.94. The PPS demonstrated construct validity through significant correlations with other self-report measures of combat experience and residual psychological distress, and through a factor analysis yielding three factors, labeled as arousal, avoidance, and the global perception of distress. Results support further use of the Purdue Post-traumatic Stress Scale as a research instrument for assessing the long-term impact of a traumatic event.     

Amitriptyline for PTSD in a torture survivor: A case study

The present study investigated the effect of amitriptyline on PTSD symptoms in a torture survivor 7 years after the trauma. After a pretreatment assessment period of 1 month, amitriptyline 150 mg nocte was started and assessments were carried out up to 8 months. An overall improvement of 70% was noted 6 weeks after the start of treatment. Improvement was most marked in depression, anxiety, and in social and work adjustment but less so in PTSD symptoms. Residual symptoms included nightmares, constricted affect, aggressive urges, startle response, and phobic avoidance. The drug effect was partial and likely to disappear on discontinuation. The limitations of drug treatment indicate the need for combined psychotherapy for lasting improvement. Evidence so far suggests that behavioral approach in the treatment of traumatic stress symptoms achieves more stable improvement.     

Warrior therapist: Vets treating vets

The practice of using Vietnam veteran therapists to treat other Vietnam veterans with PTSD is examined in terms of the impact upon the client, the therapist, and the therapy. The roles of warrior and therapist rely upon different coping strategies which produces inherent conflicts. However, the integrated warrior therapist can help warriors to make the transformation to nonwarrior coping strategies which can allow them to make better use of psychotherapy. The practice of using therapists who are trauma survivors to treat other trauma survivors is discussed in terms of its advantages and disadvantages. Treatment recommendations include a modified stance, focus on the nature of the therapeutic alliance, and personal work on the therapist's own integration of the disparate identities.     

Race-related PTSD: The Asian American Vietnam veteran

This article presents a conceptual framework by which to understand race-related post-traumatic stress disorder (PTSD) for the Asian American Vietnam veteran. The framework draws from cognitive schema theory, social behaviorism, the notion of cumulative racism as trauma, and the assumption that bifurcation and negation of one's bicultural identity is injurious. Classifications of race-related stress or trauma that may be experienced by Asian American Vietnam veterans, with exemplifying clinical case material, are presented. These types of stressors include being mistaken for Vietnamese, verbal and physical assaults that are race-related, death and near-death experiences that are race-related, racial stigmatization, dissociation from one's Asian identity, and marginalization. As studies of combat trauma and sexual assault forced the psychological stresses attendant to war and sexist oppression into public consciousness, so this article addresses psychological stress and trauma attendant to racism.     

Vietnam veteran levels of combat: Related to later violence?

The purpose of this study was to investigate whether or not a relationship exists between levels of combat experienced by Vietnam veterans and later perceptions of violence, violent attitudes, or violent behavior. Comparison groups included (1) heavy combat Vietnam veterans, (2) light combat Vietnam veterans, (3) Vietnam era veterans, and (4) nonveterans (civilians). Based upon the results of this study, levels of combat appear to be unrelated to postwar violent attitudes. Also, neither heavy nor light combat Vietnam veterans appear to engage in violent behavior any more than their Vietnam era veteran or civilian peers.     

Implosive therapy for the treatment of combat-related PTSD

Implosive therapy for the treatment of post-traumatic stress disorder is based on the principle of exposing the patient to trauma-related cues until there is a reduction in the anxiety associated with the cues. It is a relatively specialized procedure regarding which few clinicians receive extensive supervised training, despite the numerous case studies that demonstrate its effectiveness. The present paper addresses a number of procedural issues and offers guidelines for conducting implosive therapy with traumatized combat veterans. Elements of controversy regarding the application of implosive therapy are discussed.     

Screening for PTSD in a Substance Abuse Sample: Psychometric Properties of a Modified Version of the PTSD Symptom Scale Self-Report

The high rate of posttraumatic stress disorder (PTSD) among substance use disorder (SUD) patients has been documented in research protocols, but there is evidence that it is markedly under-diagnosed in clinical settings. To address the need for a brief self-report measure to identify SUD patients who may benefit from further assessment and/or treatment for PTSD, the psychometric properties of a modified version of the PTSD Symptom Scale Self-Report (PSSSR) were examined in a treatment-seeking SUD sample (N = 118). The modified version of the PSS-SR, which measures both frequency and severity of PTSD symptoms, demonstrated good internal consistency reliability and was correlated with other self-report measures of trauma-related symptomatology. Comparisons between a structured PTSD diagnostic interview and the modified PSS-SR indicated that 89% of the PTSD positive patients were correctly classified by the modified PSS-SR. The clinical relevance of these findings was discussed.     

Diverse motives for fictious post-traumatic stress disorder

Fictitious cases of Vietnam-related post-traumatic stress disorder (PTSD) present a difficult diagnostic problem. In settings where the motives of avoiding criminal responsibility or gaining financially are apparent, the clinician is alerted to possible fictious cases. But there are a variety of other reasons for fictious presentation of PTSD that the clinician needs to consider. These other reasons include psychotic disorders, concealing other behavior, gaining special attention in a Vietnam veteran PTSD role, explaining and covering up a dysfunctional life, and factitious disorder. Case examples are presented of these various fictious presentations of post-Vietnam PTSD.This brief report was accepted for publication under the Editorship of Charles R. Figley.     

Modes of long-term coping with trauma memories: Relative use and associations with personality among vietnam veterans with chronic PTSD

Little is known about how individuals who develop chronic posttraumatic stress disorder (PTSD) cope with recurring trauma memories, or how enduring personality characteristics influence such coping. Focusing on 110 hospitalized Vietnam combat veterans with chronic PTSD, this exploratory study assessed the relative frequency of using eight ways of coping with war memories, and associations between relative use of these strategies and eight dysfunctional personality styles. As a secondary issue, associations between coping strategies, combat exposure, and PTSD severity were also examined. Consistent with prior findings, these veterans predominantly used emotion-focused and avoidant strategies to cope with war memories. Differing personality styles and relative use or nonuse of particular coping strategies were also associated in psychologically coherent ways. These preliminary findings are discussed in relation to methodologic and future research issues.     

Odor-induced EEG changes in PTSD Vietnam veterans

Electroencephalogram (EEG) changes in response to trauma and non-traumarelated odors were examined in five Vietnam veterans with a DSM-III-R diagnosis of Post-traumatic Stress Disorder (PTSD) and in five Vietnam veterans with adjustment-related problems (non-PTSD). Period analysis of the EEG indicated that the odors differentially affected the PTSD group's theta and alpha activity compared to the non-PTSD group. The greatest EEG and self-report odor and PTSD effects were found in response to a trauma odor which simulated burning flesh. These findings have important implications in the detection of veterans who attempt to feign deliberately the psychophysiological response pattern associated with PTSD.     

Proactive and reactive approaches to PTSD in the aftermath of campus violence: Forming a traumatic stress react team

Traumatic stresses are becoming an increasing reality on college campuses. Unfortunately, many campuses are ill-prepared to respond professionally to the needs of victims and covictims. Even more scarce are proactive prevention programs. The problems experienced by victims of post-traumatic stress disorder are discussed. The formation of a traumatic stress response team is proposed. A developing program at a small midwestern university is used as illustration.     

Complex PTSD in Victims Exposed to Sexual and Physical Abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder

Two hundred thirty four participants in the DSM-IV Posttraumatic Stress Disorder (PTSD) Field Trial who reported sexual and/or physical abuse were evaluated. Participants were categorized according to type of abuse (physical, sexual, both), duration of abuse (acute versus chronic), and onset of abuse (early versus late). Separate logistic regression analyses examined the relationship between age of onset, duration, abuse type, and the complex PTSD (CP) lifetime diagnosis for women and men. Sexually abused women, especially those who also experienced physical abuse, had a higher risk of developing CP, although CP symptoms occurred at a high base rate among physically abused women. The theoretical implications and incremental clinical usefulness of targeting CP symptoms with abused populations are discussed.     

Cultural impediments to recovery: PTSD in contemporary America

Culture affects and determines how individual members cope with experiences encountered during the life cycle. Contemporary American culture is currently experiencing a historical transition which affects cultural standards, archetypes, and institutions such as marriage and families. This paper suggests that there is an increase in psychic numbing, alienation, isolation, and difficulties with intimacy for the general population during the present historical moment. For victims of traumatic events this current cultural stress overlaps their post-traumatic experience since many trauma victims also experience these phenomena. Trauma victims are therefore affected by rapid cultural transition through increased vulnerability to developing traumatic stress reactions as well as increased length of the healing process.     

Contextual issues in the assessment of post-traumatic stress disorder

In recent years, there has been an explosion of information on the etiology, assessment, and treatment of post-traumatic stress disorder (PTSD) in individuals exposed to a wide variety of traumatic stressors. Comprehensive assessment techniques are being developed for diagnosis and treatment evaluation in PTSD; however, there remain numerous pragmatic issues related to the context of assessment for PTSD. Issues addressed in this paper include (1) implications of the purpose of the assessment (e.g., crisis intervention, treatment planning, evaluation for compensation); (2) sequelae of the assessment, including positive and negative outcomes of exposure to traumatic memories during assessment, (3) characteristics and training of the assessor and the impact of exposure to reports of traumatic events on the assessor; and (4) features of PTSD which affect the ease of case-finding and suggest the necessity for training a variety of health care providers to recognize symptoms of PTSD.     

Post-traumatic stress disorder (PTSD) in battered women: A shelter sample

A sample of 77 battered women in shelters was examined for the presence or absence of a post-traumatic stress disorder (PTSD) diagnosis. Self-report data were obtained on battery characteristics, extent of intrusion and avoidance, depression, anxiety, and general psychopathology. Eight-four percent of the sample met the DSM-III-R criteria for PTSD according to self-report. The reported subjective distress regarding the battery experience was positively correlated with presence and degree of PTSD, intrusion, depression, anxiety, and general psychopathology. Extent of abuse was positively related to presence and degree of PTSD, depression, anxiety, and overall symptom distress. Length of the abusive relationship was least related to the outcome variables. The results of this study indicated that the shelter population of battered women is at high risk for post-traumatic stress disorder and this is linked with characteristics of the battery experience. The usefulness of these findings with regards to diagnosis and treatment is discussed.     

Patterns of PTSD among police officers following shooting incidents: A two-dimensional model and treatment implications

Shooting incidents are a rare phenomenon in low violence police work. However, when an incident occurs, the psychological impact for the officers involved may take the form of severe PTSD symptomatology. Of 37 police officers who had been involved in serious shooting incidents between 1977 and 1984 we found that 17 (46%) fulfilled DSM-III criteria for PTSD, either at the time of the interview (n=7, 19%) or prior to it (n=10, 27%). Of the PTSD-negative group 17 still showed an impressive pattern of PTSD symptoms. Only three showed no symptoms of PTSD at all. Lauferet al. (1985) presented a two-dimensional model which seems to fit the PTSD-pattern in police officers reacting to trauma. From clinical experience, it is apparent that most police officers involved in these incidents seek refuge in denial (Lazarus, 1984). Focused psychotherapy in combination with working through of the incidents and sometimes psychopharmacological intervention appear to be of value in alleviating PTSD in police officers. Preliminary experience in psychotherapy with these police officers is presented in two case vignettes.     

Post-traumatic stress disorder in children: Its identification and treatment in a residential setting for emotionally disturbed youth

In the past 5 years residential programs for emotionally disturbed youth have encountered increasingly difficult-to-treat youngsters. These children who frequently are products of physical/sexual/emotional abuse, neglect and multiple out-of-home placements, often presented with severe human trauma responses, but post-traumatic stress disorder (PTSD) was not diagnosed. This paper describes how one residential treatment center correctly identified those children referred having PTSD, developed effective treatment modalities for this syndrome in children and networked with other agencies involved in research and treatment of PTSD. Multiple out-of-home placements are highlighted as a heretofore unrecognized contributor to PTSD in children.