PART 1: An Ancient Malady

History is replete with accounts of individuals who have experienced or witnessed terrifying events, felt intense fear, helplessness, and horror, and suffered ongoing emotional distress. One of the oldest records of such psychological torment was found in Egypt, circa 1900 B.C.E., where a physician described a peculiar response to earlier trauma (Veith, 1965). In 1606 A.D., Shakespeare portrayed the mental anguish, hallucinations, and gruesome dreams of Macbeth and his lady after his bloody murder of Duncan, King of Scotland. In 1864, John Erichsen published a medical study of people who had survived railway crashes and thereafter developed "railway spine," an ongoing fear of speeding trains (Trimble, 1981).

Following the Civil War, veterans who had developed emotional distress were diagnosed as having "soldier's heart"; after World War I, veterans with ongoing symptoms were said to suffer "shell shock"; and, after World War II, soldiers with similar distress were described as suffering "battle" or "combat" fatigue (Jones, 2006). In 1901, a physician described a man who survived an industrial explosion and thereafter suffered "traumatic reminiscences"
(Lamprecht & Sack, 2002).

In 1956, Hans Selye wrote The Stress of Life, an account of his research, in which he described how stressors such as extreme fear disrupt the normal balance of life in a process he called the general adaptation syndrome (GAS) (Selye, 1976).

In the 1970s, veterans of the Vietnam War who experienced flashbacks, depression, guilt, and related problems had difficulty obtaining disability benefits because there was no accepted psychiatric diagnosis for long-term effects of such trauma (Jones, 2006).

Finally, in 1980, in the third edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the American Psychiatric Association (APA) classified posttraumatic stress disorder (PTSD) as one of several anxiety disorders. In 1994 the APA further refined criteria for PTSD in DSM-IV, and in 2000 they reaffirmed those criteria in the Textural Revision (DSM-IV-TR).

UNDERLYING CONCEPTS

Even though PTSD has been described throughout human history, veteran groups and healthcare providers have been slow to acknowledge its existence or explore its dimensions. Maybe their reticence has been due to the stigma of cowardice and weakness, or perhaps to the variability of symptoms. For whatever the reason, the disorder has been ill-defined and its treatment inconsistent. Only recently have we begun to understand that people respond to terrifying events in different ways, with different intensities, within different time frames. They respond in this way, not because of faint-heartedness or mental illness but because of the complexity of the human organism as it adapts to internal and external stressors. Therefore, before we delve into this complex response of humans, we need to review some underlying elements of this enigmatic disorder, namely: trauma, stress and stressors, memory and emotions, and fear and anxiety.

Trauma

Trauma is the direct personal experience of an event that involves actual or threatened death or serious injury to one's physical integrity (APA, 2000). Potentially traumatic events include widespread devastation such as natural disasters, mass impersonal violence, large-scale transportation accidents, explosions and fires, motor vehicle accidents, life-threatening illnesses, and war. Other potential traumatic events include interpersonal terror such as torture, rape, sexual assault, partner battery, stranger physical assault, being taken hostage, and child abuse, either as a victim or witness.

Natural disasters. These are environmental events that adversely affect a significant number of people, and include earthquakes, floods, hurricanes, tornados, and tsunamis. Fearing for ones own life or witnessing the injury or death of others is the traumatizing aspect of these events (Briere & Scott, 2007).

Mass interpersonal violence. These are vicious attacks on people by people, such as the systematic genocide of European Jews in Nazi death camps before and during World War II and the ongoing genocide of land-tilling non-Arab peoples in the Darfur region of Sudan by the Sudanese military and Janjaweed militia. Individuals who survive such horror are at high risk to develop PTSD.

Large-scale transportation accidents. These include such tragedies as train derailments, airline crashes, shipwrecks, and multiple auto accidents in which there are large numbers of victims, high fatality rates, serious injuries, and long delays of rescue.

Explosions and fires. These may be caused by gas explosions, regional fire storms, and careless use of candles, cigarettes, and matches. Fires are especially traumatic because they are so destructive and cause serious injuries that may require reconstructive surgeries and have long recovery periods. As a result, the trauma of fire continues, repeating itself over and over.

Motor vehicle accidents. About 20% of individuals in the United States experience one or more serious motor vehicle accidents (Briere & Scott, 2007). Many victims go on to develop significant psychological distress, especially if the accident causes major injury or death. Grief and self-blame magnify the psychological aftermath of such events. Survivors may sustain traumatic brain injury, further complicating recovery.

Life-threatening illnesses. Disorders are considered traumatic events when the diagnosis and treatment are accompanied by ongoing fear, further injury, threat of imminent death, and possibility of a prolonged recovery time. These disorders include such illnesses as cancer, kidney failure, and virulent infectious diseases.

War and police action. A powerful source of enduring distress, war and military action involve a wide range of violent and traumatic experiences that threaten injury or death. In addition, military action may involve prisoner-of-war confinement, extreme physical deprivation, and torture. Government acknowledgement that veterans are at high risk for PTSD has led to increasing research into the disorder.

Torture. Torture has been defined by the United Nations as "an act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining information or confession and punishing or intimidating the person or a third person…."(Vesti & Kasprup, 1995). Methods of torture include beatings, sleep deprivation, electric shock, burning, near strangulation, crushing or breaking bones, being forced to engage in humiliating acts, sensory deprivation, threats of death or mutilation, and sexual assaults. Victims of torture are at high risk for PTSD.

Rape and sexual assault. Rape is nonconsensual oral, anal, or vaginal sexual penetration of adolescents or adults made possible with threats, physical force, or incapacitating drugs. Sexual assault usually refers to any forced sexual contact short of rape. In the United States 14% to 20% of women and 2% to 4% of men report having been raped. Rape and sexual assault are risk factors for PTSD (Tjaden & Thoennes, 2000).

Partner battery (spousal abuse, domestic violence). Partner battery is the physical or sexual assault by one adult against another in an intimate, sexual, and often cohabiting relationship. Usually, there is also emotional abuse. An amazing one-fourth of individuals in the United States who live with a partner report at least one incident of physical aggression such as punching, kicking, or choking (Straus & Gelles, 1990).

Stranger physical assault. Stranger assaults are violent acts such as beatings, stabbings, and attempted strangulation by a person who is not well known to the victim. The motive may be robbery or territorial dominance by a gang. Hence, more men than women suffer stranger physical assault. In one study, 64% of men who sought care in an inner-city emergency department went there because of a physical assault (Currier & Briere, 2000).

Being taken hostage. This is an especially traumatic event because hostages are in immediate threat of injury and death and are helpless to defend themselves. They may be held for hours or days, physically restrained, assaulted, and deprived of water and food. Whether hostages are alone or one of a group, or whether they know their captor or not, they are at high risk for PTSD.

Child abuse. Child abuse includes physical, sexual, and psychological violence, ranging from severe spankings to life-threatening beatings, fondling to rape, and neglect to abandonment. Trauma of this kind leaves its victims with major psychological scars and dysfunction and with a greater likelihood of being sexually or physically victimized later in life. Even when childhood sexual abuse does not involve violence or physical injury, it is classified as a traumatic event (Classen et al., 2005).

Revictimization. Tragically, victims of interpersonal traumas such as child abuse, partner battery, sexual assault, and rape are at a statistically greater risk for further interpersonal trauma and victimization. Later traumas may lead to additional behaviors and responses that become risk factors for further trauma and complex mental-health problems. This mix of multiple traumas and complicated symptomatic responses is well known to trauma-focused clinicians, who may find it difficult to trace certain symptoms to specific traumas (Briere & Scott, 2007).

RISK FACTORS FOR TRAUMA

People respond to trauma in remarkably different ways. When a group of unrelated individuals is exposed to the same traumatic event, one person may develop a full-blown stress disorder lasting for months or years, one may become depressed and suicidal, and another may experience only mild, transient symptoms. Researchers account for such variation of symptoms by identifying various risk factors for traumatic distress. The presence of any of these factors makes people more vulnerable and more likely to develop severe symptoms. Risk factors fall into at least three categories: (1) variables specific to the victim, (2) characteristics of the trauma, and (3) social response, support, and resources available to the victim after the event.

• Victim variables. People who are more likely to develop posttraumatic symptoms are women; younger or older adults; African-Americans and Hispanics; people of lower socioeconomic status; those with prior psychological disorders; individuals with dysfunctional coping styles; people who have previous exposure to trauma; persons with a genetic predisposition; and individuals who express extreme distress during or just after a trauma (Briere & Scott. 2007).
• Characteristic of trauma. Posttraumatic symptoms are more common when the trauma is an intentional act of violence, produces physical as well as psychic harm, goes on for long periods of time, causes grotesque injury and death, involves sexual assault or rape, brings about the loss of a close friend or relative, or occurs suddenly, without warning (Briere & Scott, 2007).
• Social response, support, and resources. The symptoms and intensity of posttraumatic stress are reduced when family, friends, healthcare providers, and aid agencies provide social support and resources after a traumatic event, including their presence, acceptance, nurturance, tangible assistance, and nonjudgmental empathy, no matter what the trauma.

RESPONSES TO TRAUMA

Trauma can alter the very foundations of a person's life and cause profound emptiness, loss of hope, trust, or caring for oneself or others. It can produce all manner of disorders named in the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases, including depression, anxiety, somatoform disorders, substance abuse, psychosis, and personality disorders. In non–Anglo Saxon societies, the names of responses to trauma may be different, but the predominant symptoms are similar. For examples, some culture-bound responses to trauma are asabi, a type of nervous anger; fishar-e-bala, a mental sensation of internal stress or pressure; calorias, a feeling of intense internal heat; and shenjing shuairuo, agitated depression (Watters, 2007; Levine & Gaw, 1995).

Stress and Stressors

The concept of stress began with the pioneering work of Walter Cannon (1871–1945). He investigated the sympathetic nervous system as it reacts to threat and noticed that the body responds in a predictable sequence. Hans Selye carried on the work of Cannon, defining stress as the "rate of wear and tear on the body" and stressors as "causative agents of stress" (1991). He found that stressors may be physical, such as extreme cold, infection, injury, and pain, or psychological, such as fear, sadness, anger, and disgust. He identified what he called a general adaptation syndrome (GAS) whereby the body maintains homeostasis, or balance.

Memory

Memory is the retention of and ability to recall information, personal experiences, and procedures (Carroll, 2007). Although the structure and function of the brain has been studied extensively, there is still no universal agreement about just how memory works. However, research-supported evidence tells us:

• Memory is a set of encoded neural connections that pass through various parts of the brain.
• The stronger the neural connection, the stronger the memory; the more traumatic an event, the more likely it will be remembered (Capital Research Limited, 2007).
• Recollections of an event can occur by a stimulus to any of the parts of the brain where there is a neural connection for its memory (Capital Research Limited, 2007).
• If the brain is healthy and people are fully conscious when they experience a traumatic event, the likelihood that they will forget the event is nearly zero, unless they are very young or the brain is injured (Capital Research Limited, 2007).
• Thinking and talking about an experience creates strong encoding by a process called consolidation. Such encoding enhances the chances of remembering the experience.
• There are distinct types and elements of memory involving different parts of the brain. For example, the hippocampus stores ongoing incidents (short-term working memory); the amygdala stores emotional memories, mainly negative ones; the prefrontal cortex is involved in the consolidation of long-term memories; the cerebellum, though associated with motor coordination skills, may also be involved in remembering strong emotions, especially in the consolidation of long-term fearful memories (Capital Research Limited, 2007).
• Memories are lost because they were never elaborately encoded. Perception is mostly a filtering and consolidation (defragmenting) process. Interests and needs affect perception, but most of what is available to remember will never be processed and what is processed will be forgotten (Capital Research Limited, 2007).
• Amnesia (forgetting) is not unusual. It is the standard condition of the human species. We do not forget simply to avoid being reminded of unpleasant things. We forget, either because we did not perceive closely in the first place, or we did not encode the experience either in the parietal lobes of the cortical surface (short-term memory) or in the prefrontal lobe (long-term memory), a process that requires elaborate encoding (Carroll, 2007).
• Emotions act on memory at all points of the memory cycle: perceiving, encoding (consolidating), and retrieval (Erk, 2003).

Emotions

Emotions play an important role in the memory of traumatic events. For this reason, caregivers of those who suffer from PTSD need to understand just what emotions are, how they are experienced, and what purpose they serve in the survival of human beings. An emotion is "a complex sequence of events having elements of cognitive appraisal, feelings, impulses to action, and overt behavior; it is a feeling that accompanies an adaptive behavior for survival" (Plutchik, 1991).

Studies of the emotions have identified four positive and four negative emotions relative to the pleasure or displeasure they bring.

THE EIGHT PRIMARY EMOTIONS

• Acceptance (love)
• Anticipation (hope)
• Surprise (shock)
• Joy (happiness)
• Fear (horror)
• Anger (wrath)
• Disgust (revulsion)
• Sadness (sorrow)

Each emotion has varying degrees of intensity and may combine with other emotions to form more complex emotions, such as jealousy (sadness, anger, fear) and optimism (joy and anticipation).

Emotions serve life-preserving functions for the survival of the human species, including: incorporation of what is helpful, exploration of the environment, orientation for the sake of safety, reproduction for continuation of the species, protection against harm, destruction of danger, rejection of what may be harmful, and reintegration to wholeness when wounded.

THE EMOTIONS

Positive-Negative	Primary Emotions	Degrees of Feeling	Life-preserving Functions
Source: Adapted from Plutchik, 1991.
Positive Emotions	Acceptance (love)	Adoration-acceptance-toleration	Incorporation
	Anticipation (hope)	Vigilance-anticipation-hope	Exploration
	Surprise (shock)	Amazement-surprise-distraction	Orientation
	Joy (happiness)	Ecstasy-joy-pleasure	Reproduction
Negative Emotions	Fear (horror)	Terror-fear-apprehension	Protection
	Anger (wrath)	Rage-anger-annoyance	Destruction
	Disgust (revulsion)	Loathing-disgust-boredom	Rejection
	Sadness (sorrow)	Grief-sadness-pensiveness	Reintegration

Though emotions may be called positive or negative, in themselves they are neither good nor bad. However, the actions people take when they experience an emotion can be harmful or helpful to others or themselves. For example, unmodulated joy may become mania; uncontrolled anger may beget violence and cruelty; unresolved sadness may lead to depression and suicide; and unfocused or inappropriate fear may become anxiety, phobia, and paranoia. When an event creates intense fear, the event is encoding in memory and acute stress disorder or PTSD may result.

Fear and Anxiety

Fear is a normal, protective response to a specific danger, such as an attack by an armed assailant or the sight of a black widow spider. When individuals recognize danger (cognition), feel the emotion of fear (feeling), and have an urge to act (impulse), they take protective action (behavior) either to fight or take flight.

Anxiety is "free floating" fear of a nonspecific danger. It creates the same physiological response as fear, yet, because individuals do not know who or what is threatening them, they cannot take protective action. As a result, the fear response continues, follows the physiological sequence described earlier as the general adaptation syndrome, and in time individuals become exhausted.

At milder levels, anxiety keeps humans alert and focused, which aids in the work of living. However, when anxiety increases, adaptive behaviors decrease, physical symptoms increase, social adaptation and occupational functioning decline, and anxiety disorders follow. Thus, PTSD is classified as one of the anxiety disorders.

Anxiety Disorders

Plotted in an ascending scale of severity, the continuum of anxiety disorders identified by the American Psychiatric Association (APA) is shown below. Note the relative intensity of PTSD and acute stress disorder as they relate to other anxiety disorders.

ANXIETY DISORDERS

Source: Adapted from Shoemaker & Varcarolis, 2006.
Mild	Anxiety levels that aid in the tasks of living Psychological factors affecting medical conditions
Moderate	Anxiety disorders: Panic disorder Generalized anxiety disorder Obsessive-compulsive disorder Post-traumatic stress disorder (PTSD) Acute stress disorder
Severe	Somatoform disorders Dissociative disorders Personality disorders
Psychosis	Thought disorders Schizophrenia Cognitive impairment disorders

PART 2: The Nursing Process and PTSD

The nursing process provides a way to respond to Alex or any other patient exhibiting PTSD. Its elements include (1) assessment, (2) diagnosis, (3) planning, (4) intervention, and (5) evaluation.

ASSESSMENT

Although there is an increasing awareness of PTSD in men and women returning from combat in Iraq and Afghanistan, it is important to remember that many other individuals may be suffering from the disorder. These survivors may include the diabetic octogenarian in an extended-care facility, a new mother in a postpartum clinic, a non–English speaking immigrant on dialysis, a high school teacher having a routine physical examination, or a suicidal fireman in the ED. For obvious reasons, all patients should be assessed for symptoms of PTSD.

Clinical Interview

The most common method for assessing individuals for PTSD is the clinical interview. In settings such as emergency departments and clinics, the interview focuses on the individual's immediate safety, emotional stability, and possible exposure to further trauma. For such situations, the following guidelines may be helpful:

• Establish a level of trust before asking about a specific trauma.
• Explore the person's reason for asking for clinical services.
• Show empathy as you ask questions.
• Avoid body language or statements that imply disgust or judgment.
• Use behavioral definitions for clarity, such as "Did someone do something sexual to you that you didn't want?" rather than "Were you raped?"
• Remember, disclosure of trauma history may cause intense anger, guilt, and shame.
• Pay attention to client reactions to questions, noticing what they do or don't say, as well as what topics they avoid, such as use of mind-altering drugs (Briere & Scott, 2007).

The mnemonic ERRAND may be helpful when addressing the specific issues identified by the American Psychiatric Association in the DSM-IV-TR (see box).

Formal Assessment Tools

Although informal mental status interviews can reveal many posttraumatic stress symptoms, their unstructured nature may overlook important symptoms. For this reason, some clinicians prefer more structured assessment tools such as the following.

• Clinician-Administered PTSD Scale (CAPS). This 60-minute comprehensive interview covers all DSM-IV-TR criteria plus the impact of the disorder on occupational and social functioning, symptom severity, guilt, and dissociation (Blake et al., 1995).
• Brief Interview for Posttraumatic Disorder (BIPD). This 20-minute interview is less structured, but it covers all categories of PTSD, acute stress disorder, and brief psychotic disorder. It is less objective than CAPS but takes one-third the time (Briere, 1998).
• Acute Stress Disorder Interview (ASDI). This brief tool (15 minutes) is especially useful when the issue is acute stress disorder (ASD) as opposed to PTSD. It evaluates effortful avoidance, dissociative, re-experiencing, and arousal symptoms (Bryant et al., 1998).

OTHER TRAUMA-SPECIFIC TESTS

Other trauma-specific tests include:

• Posttraumatic Stress Diagnostic Scale
• Davidson Trauma Scale
• Detailed Assessment of Posttraumatic Stress
• Trauma Symptom Inventory
• Trauma Symptom Checklist for Children (Briere & Scott, 2007)

Generic tests include:

• Minnesota Multiphasic Personality Inventory, 2nd ed.
• Millon Clinical Multiaxial Inventory, 3rd ed.
• Symptom Checklist-90-Revised

Physical Examination

Although it may seem obvious to nurses, people with acute stress disorder (ASD) and PTSD should have a complete physical examination to check for endocrine, cardiovascular, and neurologic disorders. Furthermore, patients should be asked what over-the-counter drugs and mood-altering substances they may be taking (eg, alcohol, marijuana).

DIAGNOSIS

Medical Diagnosis

A medical diagnosis is the naming of a disorder based on an evaluation of physical signs and symptoms, medical history, and results of diagnostic tests and procedures. Box 5 gives the APA diagnostic criteria for PTSD. When individuals develop similar symptoms lasting two (2) days within four (4) weeks of a traumatic event, the diagnosis is acute stress disorder (ASD).

Nursing Diagnosis

Nursing diagnoses are "words or phrases that describe an actual or potential human response to health conditions and life processes" (NANDA International, 2007). In the case study of Alex, some likely nursing diagnoses might be:

• Risk for suicide related to feelings of helplessness, hopelessness, and worthlessness as evidenced by verbal and written statements
• Ineffective coping related to PTSD, as evidenced by an inability to keep a job, abruptly leaving his wife, and wrecking his vehicle
• Disturbed sleep pattern related to recurring and distressing dreams of fire and explosion as evidenced by verbal statements, irritability, and chronic fatigue.
• Dysfunctional grieving related to death of friend in traumatic event as evidenced by quitting job on anniversary of death and verbal and written statements.
• Anxiety related to PTSD, as evidenced by an inability to concentrate and angry outbursts

PLANNING

Planning care involves establishing client-centered goals and expected outcomes, setting priorities, and choosing interventions according to the urgency of each problem. Urgency is measured by client safety, client desires, and nature of the treatment. Using the case study of Alex, the most urgent problem is his risk for suicide, followed by a disturbed sleep pattern which impairs thinking. His dysfunctional grieving, ineffective coping, and anxiety will be addressed as he works through and resolves the distressing feelings and memories of the explosion, fire, and death of his friend.

Goals and Outcomes

The number one, over-arching goal of treatment for people suffering from PTSD is reintegration, by which the traumatized person metabolizes or internally resolves distressing feelings, thoughts, and memories. This goal influences all therapeutic interventions. The intrinsic function of reliving these experiences appears to be the processing and integrating of disturbing material. This internal working-through activity builds on the innate tendency of humans to process trauma-related memories, adapt to new realities, survive, and even thrive.

From the perspective that posttraumatic stress is adaptive, symptoms such as flashbacks, recurring images, and dreams can be considered "recovery procedures," not pathological symptoms. Thus, nurses and other clinicians see traumatized individuals not as collections of pathological symptoms but as people who are "at some level attempting to recover, albeit not always successfully" (Biere & Scott, 2007).

The second most important goal of treatment is personal growth. This is not to be interpreted as some platitude about "growing stronger through testing" or "making lemonade from lemons." It does mean that not all traumatic events are inevitably tragic. Adversity can cause people to develop in ways they never would have imagined, such as acquiring new levels of resilience, greater self-knowledge, additional survival skills, increasing empathy for others, and a broader view of life. At first, people who have suffered great trauma need safety, attention to life support, and help with painful symptoms. Later in the recovery process, personal growth becomes evident (Biere & Scott, 2007).

In the case study, the goals and outcomes for each of Alex' nursing diagnoses are as follows:

• Risk for suicide: Alex will refrain from attempting suicide.
• Ineffective coping: Alex will begin to follow-through with promises and plans.
• Disturbed sleep pattern: Alex will sleep at least 7 hours per night without nightmares.
• Dysfunctional grieving: Alex will be able to talk about his lost friend in therapy group.
• Anxiety: Alex will no longer pace the halls and will sit quietly in group.

Basic Principles of Treatment

To achieve the two primary goals of treatment for traumatized individuals, clinicians who specialize in trauma therapy agree on several basic principles:

• Respect and positive regard for survivors of trauma
• Hope and expectation of recovery
• Safety from further trauma
• Physical and emotional stability
• Consistent therapeutic relationships with caregivers
• Individualized treatment plans that are sensitive to gender and sociocultural issues, supported by every member of the treatment team, evaluated continually, and revised appropriately (Foa et al., 2000).

A review of existing literature suggests that, regardless of the theoretical stance of therapists, effective treatment for PTSD includes: (1) provision of a healing environment; (2) education about trauma; (3) distress reduction and emotion regulation; (4) cognitive interventions; (5) emotional processing; (6) increasing identity and relational functioning; and (7) psychopharmacology.

A HEALING ENVIRONMENT

A healing environment is a place of safety from physical and emotional assault. It is a haven of stability and order with a predictable schedule, adequate food and shelter, and an environment of human kindness, respect, and safety. It is a place where survivors of trauma receive unconditional positive regard, nonpossessive warmth, genuineness, and accurate empathy (Rogers, 1961; Carkhoff, 1977). In such a sanctuary, a consistent, therapeutic relationship can be established where every individual is respected and taken seriously. Survivors are admired for the strength and courage they demonstrate by their mere presence and willingness to confront painful memories.

EDUCATION ABOUT TRAUMA

Education about trauma and its symptoms greatly facilitates healing. It not only gives survivors information about the nature of trauma and its effects but it also validates their experience and helps them integrate relevant information into their overall perspective. Education about trauma is especially valuable for victims of interpersonal violence because their reality may have been distorted by their abusers, making them believe they deserved the abuse and are to blame for its consequences. Education for survivors of trauma focuses on the following topics:

• The prevalence of trauma
• Common myths associated with the trauma
• Usual reasons why perpetrators engage in interpersonal violence
• Typical immediate responses to trauma
• Lasting posttraumatic responses to victimization
• Trauma processing and reframing symptoms
• Safety planning for at-risk victims.

When education is embedded in the therapeutic context, it becomes more relevant and better integrated into the understanding of survivors. In addition to planned education from clinicians, survivors learn from fellow members of their support group and from well-chosen, timely handouts and self-help books. Regardless of the source, all educational material should be monitored and evaluated for:

• Accuracy and quality, making sure the information does not blame the victim or advocate from some social or religious perspective
• Language that fits individual reading and comprehension levels
• Cultural suitability, free of prejudicial views of race, sexual orientation, gender, and customs
• Appropriateness for the stage of healing of survivors

Sources of handouts and books are listed in Resources at the end of this course.

DISTRESS REDUCTION AND EMOTION REGULATION

Survivors of trauma often suffer chronic levels of anxiety and arousal and strong negative emotional responses to trauma-related memories. Such memories are easily triggered and difficult to manage. Because these feelings are so vivid and painful, survivors may rely on avoidance strategies including substance abuse, dissociation, and unhealthy tension-reducing behaviors such as binge eating, promiscuous sex, and self-mutilation.

Avoidance measures hinder recovery and may cause survivors to drop out of therapy and give up. To help people cope with distress and increase their capacity to regulate negative emotions, clinicians use and teach stress-reduction activities, including grounding, breathing-relaxation exercises, and emotional regulation.

Grounding

In therapy sessions, when clients experience sudden panic, flashbacks, intrusive negative thoughts, dissociative states, or psychotic symptoms, the therapist may use a technique called grounding. At these times the clinician changes the subject from whatever was being discussed to the immediate therapeutic process. To reduce such overwhelming distress, the therapist may lead the person in breathing or other relaxation exercises, or just sit quietly, acknowledging their pain. Grounding should be used judiciously to avoid implying that something has gone wrong.

Breathing-Relaxation Exercises

Slow, deep, breathing lowers tension and leads to inadvertent muscle relaxation. When trauma survivors learn how to breathe deeply and relax, they have a tool they can use at any time and almost any place. Such knowledge is empowering. Many therapists begin each session with breathing or relaxation exercises to foster the sense of control and safety in survivors. Here is a relatively simple breathing-relaxation exercise:

• The therapist models the behavior, asking survivors to stretch, then to sit down in a comfortable position, close their eyes, take a deep breath, and slowly exhale.
• Asks clients to move their feet, then relax them and continue breathing deeply.
• Asks clients to tense their leg muscles, allow them to relax, and breathe deeply.
• Asks clients to successively tense and then relax their buttock, abdomen, back, chest, upper arm, lower arm, and finger muscles and continue breathing deeply.
• Ask clients to note the pulse in their fingertips and to move a finger when they do. (This authenticates the exercise for clients and also reveals their degree of participation.)
• Ask clients to successively relax their neck, head, and, finally, their entire body.
• Ask clients to sit quietly until the therapist tells them to open their eyes and return to the wakeful world (5 to 20 minutes).
• With relatively little practice, clients can learn deep breathing and self-relaxation. By so doing, they gain a sense of empowerment and control.

Emotional Regulation

In addition to grounding and relaxation, therapists have identified several techniques to help trauma survivors tolerate and reduce negative emotions. These skills include learning to (1) identify and discriminate between emotions, (2) identify and counter thoughts that trigger intrusive emotions, (3) identify triggers and intervene, and (4) resist harmful tension-reducing behaviors.

Identify and discriminate between emotions. Many survivors of trauma have trouble knowing exactly what they are feeling beyond a sense of feeling "bad" or "upset." In addition, some individuals have difficulty differentiating anger from fear, disgust, or sadness. For example, survivors may not be able to say, "I feel fearful," let alone say, "I feel fearful because I feel threatened by…." Therapists can help survivors in this area by regularly discussing the emotional experiences of clients.

Identify and counter thoughts that trigger intrusive emotions. Not only do survivors need to identify feelings, they need to identify thoughts, especially thoughts that trigger strong emotional reactions. By becoming aware of triggering thoughts, survivors can lessen their impact by explicitly countering a thought (e.g., "Nobody is out to get me"). As survivors become better able to identify such ideas, place them in realistic context, and counter them with positive thoughts, they develop the capacity to prevent and regulate intrusive emotions (Biere & Scott, 2007).

Identify triggers and intervene. By identifying triggers in the environment and intervening, survivors gain a greater sense of control and safety. They do this by (1) noticing particular thoughts or feelings that are trauma-related; (2) evaluating the specific feature of the thought or feeling that triggered the traumatic memory, such as a personal characteristics of their abuser, the sound of a child crying, and the sight of an ambulance; (3) constructing an adaptive strategy, such as taking a "time out," deep breathing, giving themselves positive self-talk, or using a distraction, such as reading a book.

Resist harmful tension-relieving behaviors. Often survivors relieve their distress by engaging in harmful tension-reducing behaviors, such as binge eating, promiscuous sex, and self-mutilation. Although it would be best to prevent all such behaviors, in reality, stopping such behavior may be impossible, short of hospitalization. Since avoidance behaviors are survival-based, they are not easily abandoned. However, victims of trauma may be able to delay their use and develop greater emotional tolerance. For instance, when survivors are able to delay binge eating for just a few minutes, they may learn to tolerate brief periods of discomfort and in time the emotional connection to bingeing may fade (Biere & Scott, 2007).

INTERVENTION

Cognitive Interventions

Survivors of trauma, particularly of interpersonal violence, are prone to blame, shame, guilt, and other negative beliefs and perceptions. Cognitive therapy involves re-evaluating those beliefs and perceptions and replacing them with more affirming and empowering views. The central goal of cognitive therapy is to assist clients to explore and "think through" their assumptions and beliefs within the context of when and how those beliefs developed. Since the process involves verbal exploration of a traumatic event, survivors hear their beliefs, assumptions, and perceptions, and gain a better understanding of their reasoning.

As they describe a traumatic event chronologically and analytically and place it in a larger context, clients experience an increased sense of perspective, reduced feelings of chaos, and a greater sense that the universe is predictable and orderly, if not entirely benign (Meichenbaum & Fong, 1994). The retelling and the rethinking of a traumatic event somehow provides a degree of closure so that the event does not require further rumination and preoccupation. In this way, survivors develop a coherent narrative (logical story) of the trauma that upset their being so mightily and incorporate it into their ongoing life.

EMOTIONAL PROCESSING

Emotional processing of traumatic events involves exposure to traumatic memories at the same time as the survivor is experiencing safety. Over time, the expectation of treatment is that the extreme fear and horror of the original trauma (the conditioned emotional response) lessens and gradually is extinguished. Eventually, the survivor is able to remember the event without re-experiencing the fear and horror associated with it.

Emotional processing is said to follow a five-stage sequence: exposure, activation, disparity, counter-conditioning, and desensitization.

• Exposure. Exposure to trauma-memory, either as a result of thinking, telling, or being reminded of the trauma from something in the environment. Case study application: In a group therapy session with other survivors, Alex tells about the fire and explosion that killed his best friend.
• Activation. The exposure activates emotional responses that were co-encoded with and conditioned to, these memories. Alex remembers his frantic efforts to see through the flames and smoke and feels again the intense fear and frustration (anger) of entrapment and helplessness as he tries to find his way out of the debris.
• Disparity. The activated emotional responses of fear and anger are not reinforced in the safety of the therapeutic setting. Alex is sitting in a comfortable chair in a relatively nonthreatening, well-ventilated, safe place, with people who accept and care for him. He is not restrained and is free to move about as he wishes.
• Counter-conditioning. The activated emotional responses of fear and anger are counter-conditioned by opposite emotional experiences as he relives the trauma. The fear and anger Alex felt at the time of the explosion is directly opposite the safety, positive regard, acceptance, validation, and genuineness he now feels from the environment and fellow survivors.
• Desensitization. The counter-conditioning leads to extinction of the original memory-emotion association. With repeated experiences of safety and emotional support, even as he tells his narrative of horror, Alex gradually experiences less and less fear, anger, and guilt. He no longer needs to avoid the triggers he once did, nor does he need drugs and alcohol to quell his emotional pain.

Because exposure of survivors to the horror of a traumatic event can be extremely upsetting, therapists seek to control the intensity of emotions within a therapy session. Ideally, at the beginning of a session survivors are not aroused. In the safety of the therapeutic setting, they may become aroused as they process the traumatic event. As the session draws to a close, the therapist seeks to lower the level of emotionality so that survivors can leave the session in as calm an affective state as possible.

Exposure to traumatic memories may be contraindicated for some survivors, including clients who are severely depressed, extremely anxious, acutely psychotic, or overwhelmed by guilt or shame. Interventions for these clients include the affect regulation and cognitive interventions discussed earlier, psychiatric medication, and hospitalization.

INCREASING IDENTITY AND RELATIONAL FUNCTIONING

Many survivors of multiple traumas have great difficulty with self-identity and interpersonal relationships. This is particularly true of survivors of early and severe childhood trauma who have problems recognizing their own needs and entitlements, maintaining a consistent sense of self, and establishing an internal reference point in times of stress (Allen, 2001). As abused children, they may have concluded that all people are dangerous and that they themselves are intrinsically unacceptable and deserve punishment or disregard. Because of these entrenched problems with personal identity and interpersonal functioning, untreated survivors are more likely to fall victim to multiple abusers, compounding their issues and leading them into further difficulties.

Interventions for survivors with personal identity and interpersonal relationship issues are the same as for all victims of trauma; however, a safe and nurturing environment in the presence of beneficent others is especially important. From caring relationships they are able to gain a sense of personal identity and dignity and learn how to communicate assertively without submission or domination by anyone. Eventually, relating to others no longer triggers the same level of fear, anger, distrust, and avoidant behavior it once did and survivors are able to sustain positive interpersonal relationships.

Psychopharmacology

While supportive therapy is of enormous value for sufferers of PTSD, these individuals may be so overwhelmed that they are unable to participate in therapy. Furthermore, they may suffer from other psychological conditions, such as depression, other anxiety disorders, and psychotic conditions. For this reason, psychotropic medications can be useful adjuncts to trauma-focused psychotherapy, especially in the early phase of treatment.

Several classes of medications are effective in the treatment of anxiety disorders, including antidepressants, anxiolytics, and others. Among the antidepressants, selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment (Simon & Rosenbaum, 2003). Results of many randomized, double-blind, placebo-controlled studies of SSRIs indicate that these drugs reduce symptoms in the three core symptom clusters of PTSD, namely re-experiencing, hyperarousal, and avoidance. SSRIs are preferable to tricyclic antidepressants because they have more rapid onset of action and fewer side effects. Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the risk of life- threatening hypertensive crisis if clients eat food containing tyramine.

Sufferers of PTSD often self-medicate as a means to avoid or nullify their symptoms, misusing prescribed drugs or self-medicating with alcohol, marijuana, alternative herbal preparations, and various other substances. For this reason, PTSD treatment centers expect their clients to refrain from the use of nonprescribed substances. When medications are prescribed for survivors, clinicians assume the responsibility to monitor both the symptom relief of clients and their overall health status.

MEDICATIONS FOR PTSD

Generic Name	Trade Name	Usual Daily Dose (mg/day)
ANTIDEPRESSANTS
Selective serotonin reuptake inhibitors (SSRI)
Citalopram	Celexa	10–60 mg
Escitalopram	Lexapro	10–20 mg
Fluoxetine	Prozac	10–80 mg
Fluvoxamine	Luvox	100–300 mg
Paroxetine	Paxil	10–60 mg
Sertraline	Zoloft	50–200 mg
Other serotonergic agents
Venlafaxine XR	Effexor XR	75–225 mg
Mirtazapine	Remeron	15–45 mg h.s.
Trazodone	Desyrel	150–600 mg
Nefazodone	Serzone	200–600 mg
Bupropion	Wellbutrin	150–300 mg
Monoamine oxidase inhibitors
Phenelzine	Nardil	15–19 mg
Tranylcypromine	Parnate	30–60 mg
Tricyclic antidepressants
Amitriptyline	Elavil	50–300 mg
Clomipramine	Anafranil	100–250 mg
Desipramine	Norpramin	100–300 mg
Imipramine	Tofranil	75–300 mg
Nortriptyline	Pamelor	74–150 mg
ANXIOLYTICS
Benzodiazepines
Alprazolam	Xanax	0.25–2.0 mg
Chlordiazepoxide	Librium	15–75 mg
Clonazepam	Klonopin	0.5–2.0 mg
Diazepam	Valium	2.5–10 mg
Lorazepam	Ativan	0.5–6.0 mg
Nonbenzodiazepine
Buspirone	BuSpar	30–60 mg

EVALUATION

Identified goals and outcomes serve as a basis for evaluating the effectiveness of interventions for survivors of PTSD. Evaluation questions include:

• Are clients re-experiencing the traumatic event in flashbacks, nightmares, intrusive thoughts, and dissociation? If so, are these experiences less or more frequent?
• Are clients exhibiting hyperarousal symptoms such as restless sleep, muscle tension, irritability, jumpiness, and concentration difficulties? If so, are these symptoms lessening or increasing?
• Are clients using avoidance measures to evade thoughts or feelings about their traumatic experience?

Six months after he began treatment, Alex had achieved most of his goals:

• He refrained from attempting suicide for at least six months.
• He has begun to follow through and keep promises.
• He had fewer nightmares and was sleeping longer periods of time during the night.
• He was able to talk about his lost friend in therapy group.
• He no longer paced the halls and was able to sit quietly in group.

PREVENTION

Although natural disasters continue to occur throughout the world, there are many traumatic events that can be prevented. Such horrors as the mass interpersonal violence of war, careless use of fire and guns, reckless use of automobiles, interpersonal assault, and child abuse are all preventable. Not only can people prevent traumatic acts but they can also make a huge difference in the lives of survivors when trauma occurs—by providing social support and resources such as their presence, acceptance, nurturance, unbiased empathy, and tangible assistance.