Download Vulnerability, an.d the Course of posttrautnatic Reactions

ADAPTATIONS TO THAOrv'IA
CHAPTER
8
Id~l1V~c:.>
of\Vorld vVar II Pacific theater prisoner of war survivors and
veterans. Am.ericanJaumal a/Psychiatry, 150(2), 240-245 .
.J. & Waldham, R. J (1993). Prevention of exccss
.jaced POPUhllioll:; in
countries.
As\'Ociatiol1, 263, 3296-3'102.
sjJine to 10hih/a.::h
M. R. (1981). Postirmtm.atic neurosis: From.
k: Wiley.
L, L. (1993). Torture of a Nonvegian ship's crew: StTess reactions, coping, and
:hiatric aftereffects. In J. P. 'Vilson & B. Raphael (Eds.), International handstress
743-750). New York: Plennm Press.
ealth Organization. (1992). International classification oj dzseases (1 Olh
leva: Author.
R., & McFarlane, A. C. (1995). The conflict between current knowledge about ,D and its original conceptual basis. American journal 0/ Psvchiatry, 152, 15-1713. ~. (199]). Militarianism, militarization, health and the Third World. Medicine I War, 7, 262-268. Resilience,
Vulnerability, an.d the Course of posttrautnatic Reactions ALEXANDER C. McfARLANE RACHEL YEHODA If posttraumatic stress disorder (PTSD) is caused by an external traumatic even t,
do only some trauma survivors develop this condition? This question is
important, because it challenges the conceptual origins ofPTSD as a syndrome
that occurs in normal individuals as a direct consequence oftrauma exposure.
Those who have argued against the existence of specific posttraumatic syn­
dromes have hypothesized that in the absence of vulnerability, individuals
exposed to traumatic events should not develop this psychiatric disorder. On
the other side, proponents of the original idea of PTSD as a condition that
occurs as a direct result of trauma have argued that individual differences in
resilience are responsible for the lower prevalence of PTSD than of trauma.
The issue of vulnerability versus resilience continues to be highly charged
among clinicians, because it directly affects how trauma survivors must be
viewed and treated. The complex social dynamics that drive this debate have
heen discussed in Chapter '2 of this volume. This chapter reviews the evidence
lor vulnerability and resilience, by discussing f,lctors other than the nature of
exposure to the traumatic events that contribute to the development of PTSD
:md to the failure of symptoms to resolve.
One of the greatest difficulties in examining issues ofvulnerabiIity versus
1t:~iliel1ce is that the data base for the field of traumatic stress h,lS been de­
rived from retrospective studies. The extent LO which (he subjects of these stud­
ies are representative of the population of trauma survivors who would have
155
156
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ADAPTATIONS TO
Resilience, Vulnerability, and Course
TR~Ulv\A
157
OTHER LIFE EVENTS
been available prospectively is simply unknown. Although there have been
such sLUciiu; art:
recent
to exatlline lraUIlla :>w:vivors
difficult to do for a variety of reasons, not least of which is the randomness with
which trauma occurs in individuals. Nonetheless, it is helpful to elucidate the
concrete issues that can be discussed in the context of exploring vulnerability
versus resilience, and to evaluate the extern to which data have been.
outcome studies. The
of stu die,; that have primarily contributed our
understanding of the consequences of trauma have been prospective epide­
miological studies of the longitudinal course of PTSD. Studies that have pro­
vided allcillarv information are those that have attempted to characterize the
and neurobiological characteristics differentiating those who
uevelUU PTSD from those who demonstrate positive adaptations.
COPING
STYLE
FAMILY HISTORY
I
~
iii>"
'------I
.....
L _ __
,,"so",un
OTHER LIFE iI
EVEtIrS 1lI0l0GICAL
ENVIRONMENT At
TRAITS
CONCEPTUAL FR.P:o..l\·\£WORK
PAST EXPERIENCE
The longitudinal course of PTSD needs to be understood as a process (see
Figure 8.1). This process has a series of stages. First, whereas exposure to many
lraurnat.ic events is random
people cannot pI-edict when an earthquake
is going to occur), exposure tu other traumas, such as
the victim of an
assault or an auto accident(Breslau, Davis, & Andreski, 1995), may be deter­
mined by the individual to at least some extent. The way people behave dur­
ing a disaster may also h,Ive an important impact on their survival; their
experience of traumas and their training will playa role in their ability to
maximize their chance of survivaL Equally, a person's immediate emotional
reaction at the time of the trauma will influence the capacity to respond to the
threat in an adaptive way. For example, a dissociative response or a pallic reac­
tion is likely to put the individual a t particular risk. The person's state of mind
in the midst of the traumatic experience will also have a profound impact on
the way the memory of the trauma is laid down and subsequently processed.
PTSD does not develop in the immediate aftermath of a traumatic evenL
Rather, this disorder emerges out of the pattern of the acute distress triggered
the event (see
~i, this
tion to the horror, helplessness, and fear that are the critical elements of a
traumatic experience. The typical pattern for even the most catastrophic ex­
periences, however, is resolution of symptoms and not the development of
PTSD (see Chapter 7, this volume). Only a minority of the victims will go on 10
PTSD, and with the passage of time tile Sylll
\Viii resolve ill ap­
proximatclytwo·thirdsofthcsc
,\.:: ,\("i;;<m, in press).
Therefore, chronic PTSD many years after the triggering event may have some
different determinants from what people suffer in the first 6 months after
exposure to the trauma. The most chronic forms of PTSD represent the fail­
lire of healing and modulation of the acute traumatic response.
Figure 8.1 Etiological factors influencing the transition from distress to
trauma.
The factors that influence the transition from health to disorder and back
recovery are of critical interest in understanding the longitudinal course of
PTSD. The nature of this process is central to understanding the psychopatho
logical consequences oftranma. This process can be divided into three stages:
the acute stress response, the chronic response to the traumatic event, and
the individual's adaptation to
to endure the chronic symptom­
atic state ofPTSD. The acute process is described in Chapter 4, In the chronic
forms ofthe disorder, the associated disability and handicap are more responses
to the distress and disruption caused by the symptoms of the disorder than they
are primary reactions to the experience of the traumatic event. The ability to
tolerate suffering is therefore a critical determinant oflong-term adaptation.
response at each step of this process will be
by a complex matrix of biologic.al,
temperamental, alld experien rial
issues, For example, the neurobiology of an individual's stress response, the
the ability to tolerate the fear anti threat tha
to cope with any losses will be some of the fae
ultimate outcome. Some characH~ristics ill
.• bl(
outcome- These are
to
crease tbe
tors; they are generallY IlCIUIU In.,-,-,,-'''', ."..
,
a disorder or predict its course, but rather place the individual at risk of
negative outcome, One example of a risk factor is having a family history (
illness (Breslau & Davis, 1992; McFarlane, 1992). On the other hane
Resilience. Vulnerability. and Course
158
•
•
ADAPTATIONS TO TRAUMLI..
some characteristics protect the individual or favor a path to recovery. These
"resilience" factors may millimize the iutellsilY of the individual's aCute distress
or allow the more rapid modulation of an abnormal reaction. One example is
a person's ability to recruit his or her social network in the aftermath of a trau­
matic experience. Vulnerability and resilience factors may operate at any part
of the process of the su-css
is, at the time of the event, in the
immediate aftermath, or in the longer term. A particular factor mily be impor­
tant at one point in the course of the disorder but not at another.
The longer PTSD lasts, the less important the role of the traumatic expo­
sure becomes in explaining the underlying symptoms. Subsequent adversity,
the demoralization of chronic hyperarousal, and the progressive disruption of
the individual's underlying neurohiologyplay an increasing role in understandthe nature and course of chronic symptoms (see Chapter 1).
Research on the longitudinal course of PTSD is summarized below as a
to the discussion of the role ofvulnerahilit), and resilience factors.
This chapter should be read in conjunction with Chapter 7, which emphasizes
that only a minority ofpeople exposed to traumatic events develop PTSD. The
factors that influence the acute reactions to trauma are also examined in Chap­
ters 4, 5, and 13.
THE LONGITUDINAL COURSE OF PTSD
The early clinical literature about tra11matic neurosis emphasizeo the chronic
course of the disorder and the progressive social decline caused in its more
severe forms (Archibald & Tuddenham, 1956). Kardiner (1941), whose
neering work with World War I veterans had a major impact on our current
formulation of PTSD, wrote that the disorder was characterized by "deteriora­
tion ... not dissimilar to that in schizophrenia....The diminution of interest
and intelligence is due to the continuous shrinkage ofthe field of affective func­
tioning and the gratifications derived therefrom" (p. 249). Questions arise as
to whether this is the typical outcome, what is the range of other adaptations,
and whether these are modified bv the nature of the stressor,
The difft'rential effects ofdiflerent traumatic events are discussed in
ter 7. Breslau, Davis, Andreski. and Peterson (1991) suggested that the type of
traumatic experience lIlay have a major iltlpact Oll the lOllg-term course of
PTSD. Somewhat surorisirwlv, brief and circumscrilwd traumas sllch as acci­
effects Liran cornlBt
oftraurnas dCI(Ull)('illL,d in These t\vo stud
the small ltllmben; and iilllitcd
ies limit the capacity to
The Effects of War
Epidemiological studies demonstrate that PTSD tends to be the exception
rather than the rule after war. The National Vietnam Veterans Readjustment
Study (NWRS) found that 19 years after combat exposure, 1
ofveter
sti\! >uffered from PTSD (Kulka et aI., 1990). The relationship between
acnte effects of combat alld
term (JU[(o\i1C has been investigated n
in veterans of the 1982 Lebanon War (see Chapter')). This rese,
found that soldiers who became acutely distressed at the time of combat h
much higher risk ofPTSD, and that this emerged from combat stress reacti
On rile other h,mcl, the rates of PTSD among those who coped at the tin
the combat were significantly lower
This research also provided valuable insights into the pattern oj P
symptom emergence. This pattern was similar in soldiers who did an(
not have a combat stress reaction, suggesting that it is relatively indepen
of the acute pattern of response. Intrusive symptoms were also found to
low diagnostic specificity, compared to the combination of intrusive and,
ance symptoms. In addition, the prominence of in trusive symptoms decr·
over a
period while the avoidance increased (Blank, 1(93). Th~
hetween the aCllte ane! chronic reactions to other types of trau
even ts has not been so systematically investigated, because i ( is I In comlI1'
people to present for treatment in the immediate aftermath of disaste
accidents.
A number of studies in pro~ress are examining the impac.t of war bl
the civilian population in general and on specific groups of war victim
as in Kuwait. These will provide a unique body of prospective data
the effects of a largt;-scalc traumatic event. Retrospective research exa
these issues in 824 Dutch resistance fighters (Hovens, Falger, Op den
DeGroen, & Van Duijn, 1994) and found that five decades later 27(10
and 20% of women were currently experiencing PTSD. However, aith
directly comparable population sample was not available, the differer
tween this group and population norms on measures of anxiety and
sion raise an ongoing question that has not been thoroughly addresse·
study
to
date.
The Effects of Disasters and Accidents
The longltuclmal stullY uf diS;I;;t!'·!, and accident. victims
a sin
ture: Delayed PTSD is uncommon, anel the typical course of PTSD is
in the immediate aftermath of the tranma and to continue. A stue
firefighters who were intensely exposed to a rll<~ior fire disaster in th
with
han bush (McFarlane &. Papay, 1992) found that in the majorilY
;
cOllrsc. the svmptolll S t1uuumeel si::;lIitlcalldy with the passage of Ii
dut:.' not emcrge kiln! most
't\id:LC~.
PTSD was rare, and some who reported such a pattern or symptom:
recall their acute posttraumatic symptoms. In this group, only 15% J
in the absence of an anxiety disorder or major depression, indicating
is only one of a number of psychiatriC disorders that arise in such s
160
•
Resilience. Vulnerability, and Course
ADAPIATIONS TO TRAUMA
Forty-two months after the disaster, the symptoms remained in 56% of
those who bad PTSD immediately after the disaster. However, when the sub­
jects were followed up 8 years after the disaster, only 4% continued to attract
a diagnosis ofPTSD. At this stage, 60% still had significant intrusive
and symptoms of disordered arousal were as common as at 42
to reach the diagnostic threshold I,)r avoidance and
the main reaselll why these
die! Ilot qualify for ;1 diagnosis of PTSD.
he intensity of intrusive symptoms decreased significantly over time, particu­
, lady in the first 2 years after the disaster; in trusive symptoms were also less
specific to PTSD than were avoidance and disordered arousal. At 8 years, the
,.
isordered arollsal was the most prominent clinical feature, suggestiult that
anxiety and depressive symptoms were the most
of the disorder. By contrast, among a clinical population that was followed after
the same disaster, rhere tended to be a much greater stability of intrusive and
avoidance SylllpWlllS. This comparison suggests rhat quite dillercilt
can emerge from comrrnmityand clinical samples studied after the same event.
It may be the case that there are different longitudinal courses of PTSD, de­
i".~,i,,;.npnding on the initial severity. In the most severe forms, the symptoms may
relatively stable with rhe passage of rime; with the less intense forms, the
trauma-related symptoms of intrusion and avoidance may decre,lsc,
the disordered affect and arousal may remain.
The variable impact of different traumatic experience on the s¥mptol11­
OUlcome is suggested when these data are compared with th9se from a
~~~~,:;.... study of 188 motor accident victims who were assessed S0911 after the
<;}dent and followed for up to 1 year (Mayoll, Bryant, & Duthie/1993). Eigh­
percent were found to have an acute distress syndrome, ch1l.racterized by
anxiety and depression together with "horrific" intrnsive memories of the ac­
,',4<:< eident. Only 15% of these 31 victims did not haYt~ persistent psychiatric com­
. plications at the end of 1 year, with 13 having a specific phobia of travel, B
having a mood disorder or an anxiety disorder besides specific phobia, and 9
llaving PTSD. This suggests that in this setting, even when the initial reaction
has the typical features of an acute traumatic reaction, PTSD accounts for only
a minority of tht·
Olltcomc~. These
aLe) imJicdle
the enduring nature of the distress in those who develop aCLlte traulllatic reac­
Hons. Finally,
indic;:ne that hOITific llIclllories are not ubiquitol
~I~,oci­
at:d with PTSD: One-third complained
t:lese in the immediate aftermath
~f thelracCldenrs, \'vhereas only . had P [SD at 1 year.
The
It,] iOIV-, i P uf 1"I'SI) 51 dTt:1< :IS l( ) (btc W:IS ('( )lIclllCWri :1 iter
Buffalo Creek D:nn col
in r)w United St;\tes ...,.chich ClI1c't'cl :.1
flood, Grace, Green, Lindy, and Leonard (1993) conducted a H-year follow-up
of121 victims of this flood (32% of the original 381 victims participating in the
study). This rate of participation highlights one of the central problems of con­
ducting long-term follow-ups of trauma victims, and we therefore examine it in
B
en
I
0:'
•
161
more detail. 'W'ith
to stressor experiences, bereavement levels were sig­
till' those whu reflbt:d l(!
i.n t.he fnllow'lIp th:1n for
those who did. This would suggest that most follow-up studies lIla), have a bias in ~
the sampling toward those who had less traumatic experiences. This is not sur-"~
prising, given that people with extremely traumatic experiences may decline par­
in order to ,)Void reexposlIre to memories of the tranmatic event.
The main g'Oal of rhe investigation was to defille
,\Spcct:; of incli,
viduals' stressor experiences and to examine the
to which those expe
riences predicted long-term psychological impairment. The prevalence rate of
PTSD decreased from 44% in 1974 to 28% in 1986. The symptoms in this popu­
lation fluctuated with the passage of time, and this explained the emergence
of what otherwise might h,.\Ve been conceived of as delayed-onset cases. In
the severity of the symptoms in the PTSD sufferers W,IS [OUIIt! 10
decrease with the passage of time, The recovery environment may have
a role in the maintenal1l:e of symptom leveb, ;1, the flood had become a his"
torical marker that made it hard for residellts to put memories behind them.
Prospective and Controlled Studies
A unique body of data relating to these issues comes from a stud} of
monozygotic twin pairs who served in the U.S. military during the Vietnam era
(Goldberg, True, Eisen, Henderson, 1990), which found a ninefold increase
in the rates of PTSD ill the combat-exposed twill group. Tbese data
an unusual opportunity to compare the l'elative importance of the longitudi~
nal role of the traumatic experience with that of genetic predisposition in
determining the different elements ofPTSD. The effects ofcombat were strong- .
est for avoidance of reminders
the trauma (odds ratio 13.4) and intrusive
painful memories (odds ratio 12.6), and weakest for the symptoms of insOln­
nia (odds ratio", 1.8) and disturbed concentration (odds ratio = 2.3), in the
group who had high levels of combat. Thus, intense levels of combat oilly caused
a moderate increase in the prevalence of the symptoms of arousal, the major­
ity being accounted for by the background prevalence of symptoms (47% of
the
had insomnia, compared witlJ ;>,7% in Ihe
In this way, trauma may make only a minor contribution to the disordered
arousal associated with the diagnosis ofPTSD, whereas the experience oftrallfna
lllay be the lll,~or dcterminan t of the
Although otlIel .~tudies are of interest, ILiccts fur I'T51'. A 1eX;\I\r!I:r (1 (o!l(]llrtcd:l
iI1V0h't:d in oil
of 1he off.leers were free from psychiatric
, alld tbis appeared to be a
because predisaster baseline data were available on these men.
note was the lack of signs of acute distress at 3 months in this
group. However, it is difficult to generalize from these findin!!s because of the
162
•
Resilience. Vulnerability, and Course
ADAPTATIONS TO TRAUfv\A
possible
base kept Oil
citizens
a klilgiludill,tl n:conl 01 the clleClS
oflhe Alexander Kielland oil rig disaster, in which 123 men were killed
1991). The 73 survivors were compared with the insurance records of 89 oil
rig workers not exposed to the disaster. Pre disaster data showed no differences
between the populations. Increased r,ltcs ofbotlt
and
dis­
orders wen: observed for the survivors after the disaster. and this provI'cl t(l be
a pers'istent effect throughout the 8-year follow-up. The contrast was greatest
for the psychiatric diagnoses, where the rates were 12.3 per 100 and 1.5 per
100 for the exposed and control populations, respectively. Norris and Murrell
(1988) examined the longitudinal effects ofa flood and found that
symptoms were the predominant determinants of distress in this population.
Two cohorts of the Epidemiologic Catchment Area study were subse­ subjected to disasters; these provided a unique opportunity for pro­ effccts to be studied. First, the Times Beach area was found to have been built on a dioxin dump, and Hoods also occurred in the region. Following this combined disaster, the exposed population had
symp­ c•• ;J;o)J1S of depression, somatization, phobia, generalized anxiety, PTSD, and abuse. However, when the symptoms existing prior to the disasrcr were taken into accoullt, the differences were less dramatic, with
those for de-
l . pression and fYrSD being significant. r11 contrast to the symptoms of PTSD,
i;;~'~where the symptoms occurred de novo, the depressive symptoms were a recur­
!
rence of pn~viuus sympt(>llls. Many of these symptoms had resolved within a
"yehr'of the disaster. Second, the Puerto Rico cohort experienced a hurricane
tpat involved loss of life and property, and similar findings were obtainc'd
"ilomon & Canino, 1990).
tudinal effects of trauma are c:pmplex. They include the
initiation of new symptoms (particularly those oflTSD), but also the emer­
gence of symptoms
of depression and anxj'ery) that represent both the
onset of new symptoms and the reactivation of prior affective distress and
. hyperarousal. However, the trauma may serve to further increase the
that these symptoms will become autonomous. PTSD is a syndrome that appears
to have a variahle COUt:<c. and rhis COllrSf' app(,ar~ w be ;,ffected
. of the precipitating event, the characteristics of the traumatized individual. anel
the nature of the recovery environment.
{if'
:E.J,'rl:..crrs
()F
LC~l\i'G "'rRAU/¥l,r·~. As currently conceptualized, the definition of PTSD is insufficient to describe
the full range of the effects of trauma (see Chapter 9, this volume). This range
not only has important theoretical implications, but is often forgotten in the
planning of treatment services for traumatized populations.
•
163
Comorbid Disorders
The current tendency to focus excl
on the trauma may prevenl the
adequate assessment and treatment of comorbid disorders such as depression
and substance abuse. Recently, the range of specific trauma-related disorders
has received more attention, as has the nonspecific role of trauma as a trigger
fe.r ~1 range of psychiatric disorders. There is a consisten t finding across a vari:""
ely of traumatic even ts th'lt PTSD is only one of a number of psychiatric disor­
ders that can occur in such settings. In fact, in t.he majority of cases even in
community samples, PTSD is usually accompanied by another disorder (e.g., /' !
Ill,'U or depression, an anxiety disortier, or substance abuse) (Kulka et aI., ] 990;
McFarlane & Papay,
. , /
Such findings call into (luestion the longitudinal relationship between the
experience of traumatic events and these other disorders. Interestingly, some
victims of trauma do not develop PTSD but do develop other disorders, such
as depression. On the other hand, while PTSD goes into remission, other dis­
orders may hecome active. In populations of
psychiatric patients, the
role of trauma in these patients' problems is
underestimated, because
of the apparent dominance of other disorders that are not obviously linked
aumatic precipitant.
The relationship between traumatic stressors and general vulnerabilityto
psychiatric disorder may vary significantly among different populations. For
the Grant Study, which has followed the health of a group of sopho­
mores recruited at Harvard University until the age of
found that
occurrence ofPTSD was unrelated to the variables that predicted poor psycho­
logical health on a range of other parameters (Lee, Vaillant, Torrey, & Elder,
1995). This contrasts with the findings of other studies, which have not exam­
ined such an elite population. For example, Schnurr, Friedman, and Rosenberg
(1993) found [hat Minnesota Multiphasic Personality Inventory scores
to combat predicted subsequentPTSD. The National Comorbidity Survey (Kess­
ler et aI., in
and Breslau and Davis (1992) have shown t.he role of prior
disorders and family history as predictors ofPTSD.
There has been surprisingly little research examinirw the extent to
which trauma
a role ill the Oll::.e[ and maintenance of
various disorders. However, several
ions have now looked
at the prevalence of child abuse in clinical sarnpks and found prevalence rates
on the order of 18-60%
et ai., ]993). Davidson and Smit.h (1990) alld
McFarlane (1994) have abo found that in
patient s;mmles the lifetime
tiv
underestim,\
[eei.
rates (\ f I'TS \) are
Multiple Forms of PTSD
In any attempt to understand the longitudinal consequences of trauma, it IS
important that information be derived from a range of victim groups, because
164
•
Resilience, Vulnerability, and Course
ADAfYIATIONS TO TRAUh\A
he th,.:
COl1G'rn of
a number of studies have noted all increased
cal symptoms in persons with PTSD, the reasons [or this association are unclear
(McFarlane, Atchison, Rafalowicz, & Papay, 1994); a number of possible ex­
exist. First, physical symptoms may be an integral part of the con­
stellation of sympLOnlS thac constitutes rTSD. If ~n, PTSD would be similar in
this respect to panic disorder or major depression, in which
either are physical concomitants of the disorder (e.g., shortness of
breath or palpitations in panic disorder, and sleeplessness or weight loss in de­
pression) or occur yia somatization (e,g., pain syndromes in depression). In
these disorders, physical symptoms are often the focus of n:1 rien ts' distress and
Wilh
!~.
Itftpact on 8eliefs and Attitudes
Impact on Physical Health
The
a::~l::;eJ
(>I'r[,::l1
]"
p:lrLC:fll nf{-t~':';(H..:iatt:d
, The'
synlptorns aris(-~s
as part of the rraumat.ic stre~s respollse, Historically, PTSD was described by a
series of names that focused on the physical accompaniments, such as "soldiers'
heart" and "railway spine" (see Chapter 3, this volume). The controversy about
the effects of herbicides on the physical health of Vietnam veterans similarly
165
how even in more recent times, the physical symptoms associated
the outcomes of different types of traumas may vary substantially, For example,
clinical
Sl1ggC~ls thai Ih(~ IUl1g-rerm conscqul'IllcS of c;lild ahu"c
are very ditTerent from those of a natural disaster or other circumscribed trauma
in adult life (Herman, 1992). Victims of childhood abuse are more likely to
have amnesias of the trauma and a range of dissociative symptoms (Saxe et
19(3) ,
Blank (!
has highlighted t hat the longitudinal course of PISD has
multiple variations-namely, acute, delayed, chronic, intermittent, residual, and
reactivated patterns, Longitudinal studies like the NWRS (Kulka et aI., 1990)
and the Grant Study suggest a need to define a posttraumatic syndrome in which
the full PTSD criteria a.re not meL Arl issue that has not beell explored in
is whether there are significant variations in the presentations ofPTSD over time,
such as interpersonal dysfunction's becoming more prominentwith the passage
of time, The impact of trauma on personality is specifically addressed by van der
Kolk ill Chapter 9, This is a critical question, particllbrly among people who were
subjected to prolonged and recUlrent trauma in childhood.
Trauma can also have a series of longitudinal consequences other than the
onset of psychological disorders, The experience of such even ts call modify
individual's vulnerability to subsequent traumatic events, even in the absence
response, In particular, the mealling of a threat or traumatic
~i!:,J()Sscan lead to a major shift in an iyidividual's internal perceptual sensitivities
Kolk, 1989), Equally, sucH experiences can become powerful sources
~bf.motivation for some individuals, indicating that trauma can have positive
on those who survive the ordeal; it need not necessarily result in an
sense of demoralization or of having been damaged. The role of the
memory of traumatic experiences as a source of motivation and a determinant
of human behavior is an issue that is one of the major preoccupations of lit­
erature and art. This is an indication of how the impact of such experiences
on values and beliefs has importan t implications for both individuals and soci­
ety, The accommoclarion to 1he rll)~sibility of loss and rhn',l1 of'danl,"!'!' Dlav:" ,1
central role ill sh<1Pin[f mallY social attitudes and responses.
•
!·~· ,.
I
i .
,
,
;:-
,
r,·
.'.-.•. . . ,'.. . .,::.;?.:.' . ' ,,1
::,-,~
",.
,~:
#'..
h,
1~;:'i,::"--:
PTSD
CUI
the main cause for consllltation with Second, the physical symptoms may be directly caused by the stressor responsible for the development of ITSD. In mallY instances, the stressors are life-threatening evelllb such as accidents or cOlllb:1t, which came physical to many of those exposed. Henedicl and Kolb (1986) describe a sample of war veterans ",.jth undiagnosed PTSD attending a pain clinic. In all these patients, pain was localized to the site of a former injury. In this situation, the development of PTSD may influence the presentation of the :iylllptolllS rather than their onset. Third, physical symptoms may be a nonspecific response to exposure to a tra1lmatic experience, independent of the development ofPTSD, of this question ha$ important practical
for the assessment of patients who have been exposed to traumatic events in which they may have been injured-particularly when the symptoms become the subject because their cause is often disputed. The presence of physical symptoms in the absence of an obvious cause should raise the possibility of undetected PTSD. The majority of studies examining the relationship between physical symp­ toms and trauma have had war veterans as subjects. For example, Solomon and Mikulincer (1987), reporting on somatic complaints among Israeli soldiers I year after their combat experience in the 1982 Lebanon 'War, fOUlld an increase in self-reporting of physical symptoms among soldiers with acute or chronic psychological reacrions. The existence of physical svmptoms was also related to the use of new medication, alcohol consumption, cigareneuse. and PTSD. Shaiev, Bleich, and Ursano (1990) compared Lebanon vVar veterans with chro­ nic PTSD to matched C0l11haL veTerans withoutPTSD, The PTSD group
higher rates of canjiovas(ubr.
'Chi,; raises l.he
111
pruccs~) or that then.. "~\rc
in the \\';1\Y P'TSiJ
sufferers yv.
t' " " .. , "'-­
Many variables in combat veterans make extrapolation to civilian populations
difficult, including bias in the initial selection for military service, the nature of
the stressors of military life and combat, the nature of injuries sustained in com
1 L
L
'"
166
•
Resilience. Vulnerability. and Course
ADAPTATIONS TO TRAUMA
bat, and the effect ofpension en ti tlement schemes. Escobar, Canino, Rubio-Stipee,
and Eravu (1
Lin the
telll
Orll(~\\'
:-.yrnpLoH1:->
year
,\fter a natural disaster in Pueno Rico. Victims of the disaster were more likely to
report new gastrointestillal or pseudoneurological symploms than persons not
exposed to the disaster. Although these symptoms may have been indicators of
psychopatholog;', no correlation was made with the pn':;c]1CC of psvdliatric ill I]("S~,
The Grdlll Studv Il<I~ t;"all1ined dw impact of (oll1l>ar (Lee el :11" I
Subjects in tlIis study were selected for their physical and psychological health
and high levels of achievement at Harvard University. AJthough 72 had a high
level of combat exposure, only 1 retrospectively satisfied the diagnostic crite­
ria for PTSD in 1946, with another 4 having a PTSD-like syndrome. (Of these
five, t\NO committed suicide, one became withdrawn and dropped out of the
study, and another was murdered.) This suggests that PTSD is the exception
among a group of highly competent and resourcefnl individuals. However,
corn bat expo~llre predicted early death, independent ofPTSD:
of tli e men
who had experienced heavy combat were dead or chronically ill by the age of
65 (Lee et aI., 1995). The length of follow-up in this study makes the results
especially noteworthy, as these long-term effects of trauma may only emerge
in old age, when the risk of physical illness is increased.
Similarly, the mortality of World War II concentration camp victims was
much higher than in control populations and was most marked in the youngest
age groups. The death rate was highest among those in the death camps. The
:~uration ofirnprisonment hod no influence upon the mortality, perhaps because
.F'viyalreflected a positive selection factor. The initial deaths were due to infec­
",~ousdiseases, whereas in the later period coronary arterial disease, lung can­
~Xrc.~t7;:and violent death were especially common (Eitinger & Strom, 1973). Slmi­
I:;'l~r l()ng-term health effects were observed among the merchant seamen who
i.,.sail~d the convoys in the North Atlantic in World War 11 (.A..skevold, 1980).
I
(.
[. aehavioral and Interpersonal Disability
I,;and
Handicap
I·"·'
i The impact of trauma on the he havioral and
tims has also undergone little investigation This is
popular prejudices that emerged both ill the 1880s in r<:iatioll 10 "railway
and also ill the aftermath of Vv'orldWar 1 was the !lotio!1 that the calise oftrau­
nlatic neurosis was the pa}"lllcl t L of compens,uion. Thi;; k:d the Germans to pal'
:10
for tr~tllln;I..j"I'·hi<'cl rlisn(cl"I's ill the :If'I'>1'!l1,III' "ft
IV;!!', and
U}
;;;uJrereJ',"> frorn
reacil(.'l)S ill
World War 11. There han: nUI\ lJeCll four studic:i that han: examilled tht: im­
pact of cqmpensation on the outcome ofPTSD (see Chapter 16, this volume).
First, a study on victims of the Buffalo Creek disaster (Grace et aL, 1993) com­
pared a group who went through a litigation process with those who accepted
•
167
an uncontested payment and found few differences in outcome. Mayoll et al.
fUlllld ih,,:
in\'olVfrl in
did not :lffe'cr thl" Ol1fcnme
of motor accident victims-a similar finding to that after the Pan ,\Illtrrican
Flight 103 Clash over Lockerbie, Scotland (Brooks & McKinlay,
tion also did not affect the outcome of the victims of the 1983 Australian Ash
vVcdnesc\3y disaster, although they felt very trallmatized
the litigation pro­
ces~
ill pres;; b). Thus,
lraUilL"c can 11:\\'(> clram:ltic df(~ct~
on the: ability to perform in <I variety of social roles, this variation canllot be
substantially attributed to the payment of fll1ancial compensation. However,
defining the optimal system for paying compensation and maximizing victims'
1I10tivation to playa useful social role are matters of critical concern.
It is important to distinguish the severity of individuals' symptoms from
their ability to perform a range of social roles. For example, in the Grant Study,
one of the men who was most troubled by traumatic memories o[war became
It of the United St,lles-::]nlm F. Kennedy. As noted. above, some
can have positive adaptalions to trauma, using their
as ~ollrce of"
motivation. For others, work becomes a method of distraction and ofkeepi ng
the past at bay. Although their careers may be very successful, this success may
be achieved at the expense of their family and in terpersopal rebtionships. Still
others become crippled by the intrllsiveness of the past and Iheir inability to
focus,on the present.
social consequences have perhaps been best
of concentration calllp \ictirn survivors (Eitinger &: Strom, 1973).
h,ld less
stable working lives than controls, with more frequent changes in jobs, domi"
ciles, and occupatiolls. There were transitions roless qualified and well-paid,
work in 25% of the stuvivors, in contrast to 4% oftlYe controls: The ex-prisoners
from the lower socioeconomic classes seemed to be less able to compen­
health than the more professional and skilled groups.
demonstrated that the absences h'ol1l work and prob­
lems with occupational functioning were accounted for not only byPTSD symp­
toms, but also a variety of psychosomatic complaints, conversion complaints,
and vegetative symptoms.
The ~'VVRS (Kulka et al., 19(0) examined the impact of Vi ern am service
in
detail and indicat.ed that, as a group, veterans were
III
a variety of educational and social domains. This conld !lot be accounted for
by the payment ofpellsion entitlements for PTSD, 'IS ..1
per­
centage of those cntitletl chose not 10 receive
Ilmvevcr, this issue
;, \'" heen il1v,,;1
,ng rhe rlo,ooo Australian VicLiU!ll veterans who
~\;'CI'C no~ f<:Jlilld [U
chs~!d\!(tll
(--;',\(';1(\
cunlIllUnicalion). This highlight:, how cultural issues and t.he ,\y;uJable ,ocial roles
may also playa central part in determining the impact of PTSD on the levels
of disability and handicap.
The relationship between symptom improvement and function has been
168
•
ADAPTATIONS TO TRAUMA
f<esilience. Vulnerability, and Course
examined in a group of Israeli war
lev(:b
~(\(
".I illiel
ldJ()!lIV(;re l()lllld
This suggests that these consequences may be more resistant to
remission than the intrusive phenomena. The potential for the social disloca­
tion that can be caused by this disorder was demonstrated by North and Smith
, who ['"urld
PTSr! W;l~ Oil("' nfllle r:l'),[ (omll1on
disur­
ders <Jl\wng IhL' hOrlwies;; and that their clisonl,:l"
r;lrhe; Ihall lxii:g
caused by their homelessness.
Another aspect of the behavioral consequences of trauma was shown in a
study of Australian female prisoners, which demonstrated that PTSD and a
history of abuse were almost ubiquitous in these women, and that these fac­
tors contributed
to their crimina! histories
Sha\,·, R.:
McFarlane, 1995). The
of the trauma history of attenders at a dn 19
rehabilitation clinic
found a strong association between PTSD and tlIe
abuse in
of cases (fullilo\'{; et
ill it~
PTSD leads to a severe social decline that is associated
social groups. A comparison of PTSD
to
disorders showed that the PTSD group had a worse
outcome OIl a range of dimensions of fllnctionin~ (Warshaw et a l l " In
this longitudinal study in a clinical settiug, PTSD was found to have severe effects
on quality oflife in virtually all domains. The PTSD patients also had hillh levels
: of depression, suicide attempts and gestures, and alcohol abuse.
Given the enormous COSts offinancial compensation for the effects of trau­
~~matic stress, and the fact that the amount of compensation is often determined
the severity of the associated disability, it is an extreme paradox that this
~"',J\~'<ir"'''; has been so little investigated. It is also a critical issue for treatment, as we
not assume that the ill terven tions that improve
symptoms of
and hvoerarousal will alllornatically modify their
to work or
we do not even know which of the postThe role that
and attiis of critical interest. For
it is probable that individuals who have a stoical attitude are more
their symptolnclflc di~tr('ss tf)
Sldt~ aBel n1~linta!n f heir usual le\'els uf func­
tioning, despite their
Another matter that has not been invcstigated i~ the
of return­
ing people to work in jobs \Vh ere they have becll traulllatized
emergency
service workers, or bank employees who have heen jnvolved in a holdup). Does
the
t() \\rork ha'.'c ;l lI\.:,~~tli·\>'L ~uIl~-LCrjil illlP~lCl Uli their
jbev maintain ,ht"ir :ior:i:tl rn;(:~ Does III le'lrl 10 rl1<"
rct'urll
(HUILsuneflC
''!If <'["
the use of dissociative defenses: At what point is such a return to the trauma­
tizing environment
an individual's interests?
not to nlake re­
turn to work a
of rehabilitation can be very detrimental to an individual's
sense of masterv and
•
169
Modified Vulnerability to
Disonkrcd Affect and AronSi'll
in the literature about the outcome of the
can be IlSf'fllllv aDDlied to the
treatment
LiOll()J:ll
anses
how tu
I l'C:>\'Tl1 I
a rli,"'rdcr
:ll:d rcc:pvCl")'
from ie This is an important concept, because the term "recovery" defines
end of an illness episode and presumes that a further episode is a recurrence
of the disorder rather than a relapse of the current one. III medico-legal circles,
where the prognosis of PTSD and its long-term outcome are of particular
there is an assumption that once the symptoms of PTSD have
resolved, the disorder does not recur. This is based on the idea that PTSD
is an aclaptational response to an event (Yehllda &:
spollse that
with an acute stn~ss reaction, then follows a
COllrse, and eventually resolves without
that this is Ilot the case. In
35 soldiers who had several exposures to combat
<:1'1""UD ofPTSn. There was support for the concept of reactiva­
tion of the
PTSD in some
whereas in others the second
sode may have been substantially independent of the firsL
Both clinical and biological data
that in a significant number of
individuals PTSD causes significant psychological and neurobiological changes,
which endure even after the disorder remits. These mayinclude a permanent
modification of the illdiviclual'? vulnerability to a range of psychiatric disorders,
which mayor may not be triggered by subsequent adverse life experience, Mell·
man, Randolph, Brawman-Minrzer, Flores, & Milanes, (1992) have suggested that
the comorbid disorders triggered in relation to PTSD, particularly panic disor­
depressive disorder, and phobias, become increasingly autonomous
of recurrence. This propensity of the concurrent disorder to have
a recurrent course may in fact be one of the critical
consequences of
trauma
& Papay, 1992). A further issue is whether the constellation
;,)lllpLOillS ill PTSD
with the
the interestrangement and emotional detachment may cow£: to dominate the
as the intrusive Il1<:IIH,ries bl':come less dornin;lnt. This may have
lant implications for treatment, as the effectiveness of different strategies lllay
to the stage of the disorder (McFarlane,
"11w 1l1ndc]ofkill(ilillg ill "th:(liH~ di"olciers ha~ bCUl ,[,;\CIUPL:cl fn)ill lhe
clinlc:ll uhscrvatioll th:lt liC(·
\'\I(:!!T"
p
~H1 irnp0r1;tnr ifli!J';llin;~ r()le 111 th(~
first episodes of an affective disorder, but that their importance progressively
decreases as the neurobiology of the disorder becomes autonomous (Post,
1992). This model implies that there is a "biological memory" of the preced­
episodes of the illness, and that the individual's current vulnerability to
170
•
ADAPTATIONS TO TRL\UMA
Resilience. Vulnerability. dnd Course
•
17 I
affective
IS a consequence of this pl"Ogressive sensitiviry to affective de­
stahilizali(lll. The
,kll rhe ')lllPlOIl1S ()f PISD are Illailllaillcd and
day-to-day adverse life experiellces, and that this process is a stron­
of current levels of symptomatic distress than the original
trauma, suggests that a modification of the individual's stress responsiveness may
be an
'a~p(,cl oftlh' d,:;, i!i:ll;i)[; iiJai is ",;;::1';11 to tile FSYc
of PTSf)
I (1<'1' KoiK, (:reen
Hoyd, &:
L I
Koopman, Classen, & Spiegel,1 !J94). The work of Resnick and associates (cited
in Yehuda, Resnick, Kahana, & Giller, 1993a), who found altered cortisol respon­
siveness in women Who had been raped on a second occasion, indicates how the
COUrse of PTSD needs to take aCCOUnt of the similar
of stress
responsiveness that are thought to be in affective disorders.
Therefore, research on t.he Course of PTSD and other post­ traumatic states needs to consider the that even if the
of the immediate disorder remit, penn:ment cl\;rnges may remain ill the
individual's vulnerabiE ty to disordered affect and arousal. The
neurobiology may be similar to that found in affective disorders, and vall der
Kolk et al. (1985) have proposed that kindling is a useful model to explain the
changes in PTSD, Yehllda and Antelman (l99'~) have also
model of sensitization can explain the in this VULNERABILITY AND RESILIENCE:
POSSIBLE FACTORS AND PROCESSES
Do Vulnerability Factors Modify Response to Stress? It is necessary to be precise about what vulnerability does predict. Critical to
this issue is the question of how individuals who are exposed to a traumatic event but do not develop a psychiatric disorder differ from those who develop PTSD. In particular, are there specific symptoms that differentiate people who survive a traumatic
without Iwi
di.<;;-ihlnl from those who become . symptomatic? Fpiderniological stlJdie3 of populatiolls ill the illirnecliate after­
math of a trauma, alld even stlJdies of COlleen tr~ltiOll carnp sllrvivors ~() Veal'S
after the Holocaust, have found th<lllllallY urthe victims have intrusive lllelllO­
ri<:s of the trauma and SOllie avoidance phenomena but do not have PTSD.
ir
h
'Id,!:: I]LI
ire; Cllt Lut(H,; tUiiLrilJutc 1.<> llw diifC'rS}Tnp{UU1S. h
[he: CL~C ih;H the
nr'rij.-':()j'fh'H:'d
ilrQus,d are the vUlnerabililY Clctors that best distillguish tbose with PTSD.
Epidemiological studies are especially important in understanding etiol­
ogy,as discussed in Chapter 7, because they allow comparisons of PTSD suf­
ferersto
individuals who have been exposed to the trauma but have not devel­
~
,
If
I','.:},.•
I
.
oped the disorder. In particular, PTSD cannot be
entirely by the
clllergence of traumatic IlIClllOrltt:i and r1w IlssocidLcd
[Ii ': and
processes, as these traumatic memories are present in many of those without
PTSD. Thus the biology of memory is not a sufficient model to explain the
characteristics differentiating those with PTSD from those who do not remain
UiSll "ssed l(!lloKinQ 11:
1111: • • d;Lcqwh it i~ it critic;ll inv'l'mediar\, procesr;
ilIt~ emergence of symptom,. n( disordered arousal.
The many studies of normal stress reactions may also be less relevant. than
is often assumed, as they do not deal with the variability of response that is C1iti­
cal to pathological outcomes. This is particularly the case in the light of (he find­
of hypocortisolemi a and supersuppression on the dexamethasone suppres­
,ion test (Yehucla et aL, 1999b), These findings demonstrate that the biology of
PTSD is not the biology of the "normal" acute stress response, This is a critical
because models of animal stress are often used to develop hypotheses abollt
the etiology of PTSD; in
, these paradigms ImlY !lot bl~ :tOolicable. Simi­
many of the studies that are used to discuss the role of
refer to the investigation of memories of situations and experiences that are far
from traumatic (see Chapter 12). Therefore, any model of predisposition or
should aim t.o explain the emergence of the features of PTSD that
differentiate it from the normal stress response. The study by Resnick et al.
in Ychuda et aI., 1993a) is of particular interest in this regard, as it demonstrated
that women who had heen previously raped tended to have a lower acute corti­
sol response to a subsequent rape than women who were raped for the firsl time.
This pattern of reaction was associated with an increased risk of PTSD, which
indicates that the normal stress response (with a characteristic mcUor surge in
cortisol) may protect against the development ofPTSD.
Thlls the concept of vulnerability is more complicated than it first appears.
KaTdiner (1941) suggested that the role of vulnerability facmrs in the devel­
opment of acute symptoms differs from their role in regard [() the chronic
outcomes. The natural course of acute distress may be to
finding
highlighted by Weisaeth's (1989) follow-up study of a factory explosion. Chronic
PTSD was associated with preexisting vulnerabilities, complicating life even ts,
awl 10'.\ Iltotivation;
Ir:1l1rn;, exposllre was necessary, but. not
the emergence of chronic symptoms. Therefore, IGwcrcd resilience may be more illlpm·tani. in preventing the resollltion and amelioration of the acute distn'ss than ill determining irs occlIcence. Hence, vulnerability call influellce a series of diffcrcll t :;teps ill the elllerL~t:jlCC uC
I«)llic
i ;-irht'r a
or
\'.fay at C(1ch -"rep. F
l:\'Cl It.'; ~li(:h ~IS
combat, rape, or assault is uftell :ts.'llllled to be the critict!
onset of chronic PTSD. This particularly prejudicial view accounts for much of
the stigma connected with PTSD. It erroneously assumes that fear is the cause
ofPTSD, rather than the sense of threat and horror that becomes imbedded in
[72
•
ADAPTATIONS TO TR4W,\A
Resilience. Vulnerability, and Course
the memory of an inriivi(hlal who may have
well at the time of the trauma.
The parado'( i~ tklt ilie
;, Il() eli
link j)<:.'tW<TII all lildividuai
alld
the existence of PTSD. For example, in World vVar I, men who developed shellto be decorated as other
and officers with PTSD
among those
for the
I;,
•
[ 73
that are central to PTSD (Calletly, Cbrk, &
ety, and
to subside ill the first weeks was a malor predictor of
PTSD. These obsen'ations may allow llS to begin to define high-risk indi\'idu­
note of the fact that
of exposure and extent of losses alone
The factor, that facilitate or prevent the oo~et alld
I,f
.-'
of
of stress re­
sponse are therefore of primary interest in
vulnerability and
resilience. Although it is truc that soldiers with combat stress reactions are more
likely to develop PTSD, PT5D is not an inevitable consequence
Solomon
et al., (;hapter 5). iYlany individuals who develop PTSn after combat have Hot
had an acute stress reaction. This is also true of other traumatic events: People
wllo have becn dblc tu re~p"!ld <llld manage in the EKe nftl!e immediatc tr;nlllU
add sutfering bler SUCUllUb lu dlc disonler. Tl1erelore, [ile link between the:
acute response and 1'T51) iS!lOl a simple one-to-one relationship. '1'he pattern
of acute response, as discllssed in Chapter 7, call be critically deterll1ined by
the nature and predictability of the tl'<lllma.
;\ range of acute stress re;\,­
tiOIlS IlIay need to be considered in relallon to res.iiience. Furthermore, thf'V
may directly lead to PTSD, and hence it is necessary to consider the de tel 111 i­
nants of chronic oosttr;l1lm:l';{' states as a separate issue.
t
II:
f
Jit
tIt, It
.'ii"TJ.\~Role of Vulnerability in the Initial osttraumatic Period whether an individual's arousal normalizes Ips been triggered is a critical process in the to an event.
The modulation of an
a range of vul­
nerability factors. Tn the initial
after a traumatic event, distressing and
intrusive recollections of the traumatic
are universal and indicate
i:m ongoing process of normal reappraisal. In this process, various representa­
tions of the trauma are '~ntenaillf'cl, ;>I1<1;m
is m,lde to il1tegl'Cltc rtF""_'
with existing psychological schemata. Tbis
of these memories allows
-·the development of novel
constructs that an: !lot part of the indi­
vidual's illlltT \Yodd (see Chapter
The cmcrgellCl~ of ,Ill endurillg'
:;tank response,
ilance. inc(c:l:-;('d irrif:d',ili
~\)'I(! (!' urb,,·c! nH::ill()j} ~1;1\~
j
COt1cc:rltr:ttJc);, i,~ \\'h;.~t djilcrcll
'!n,' \'iCl1nL"l \\"}J{,,SlJ \)11 to
may
their own resources are
or
to terms with the
Several studies have now shown that the relatiollship between illtrusive
lions and arousal is less apparclIt in the immediate aftermath of the
~ <lllill],::)l
di."V·ch';!J iJCj',Si)
(Weisaeth, I
Mcl-\ulallc, I
Tllis h;peral'ousal arises as a consequence
of the constant replaying of the traumatic memories. The evidence for this
relationship comes fwm
data (McFarlane, 1992; Creamer,
Burgess, & Pattison, 1992) and
the basis for a neural network model
becomes apparent after a few
of
injuries may take some time to be­
cOllle apparent, and the extent of both the destruction of property and the
number of deaths may only become clear at the end of extensive rescue and
containment efforts. The ultimate meaning of the experience will be COll­
siructed frpm its
(If donl,tins. These p"rcepliolls arc i111111­
enced
ItauilLldl cupillg s~ill~, auJ gCIH..:ral,~lr0u;;;,abililY \ Freedy,
& Kilpatrick, 19(2). The ability to mobilize appropl iale
relationships and support is another critical issue at this stage of the process
of adaptation.
ft\e progression from a st.at.e otdislress to more severe syrnpt.Ollls is ilJfill­
elleed hy a range of other vulnerabilities, illcluding a past or family history of
psychiatric illness, neuroticism as a personality trait, a range of social mcdia­
tors, and other life even LS or traumas OCCUlTillg after the disaster
et a!.. in press; Breslau & Davis, 1992; McFarlane, 1989). It is important to
once
that the development of chronic symptoms is the ex­
ception rather than the rule. Exposure to extreme stress can produce personal
and lead to increased self-respect. Many people go through a process
their values and priorities. In any consideration of the
with an individual's resilience and
in mind. At this
of
Ii II 111
I,'
Ii
Ii
litl:!l1Cf" .~:'nlJHonl:~ Cd1h· c·'j
ltVt
;1
Sell'..'"
~, ~.~ ~\.Li~::llLl}ccr, t ~n·;
of se\'cral weeks, the typical cOl1srclbtion uf PTSD
lU bc luall i­
fested. At this early stage, the intensity of intrusions is probably not a
measure of their psychopathological significance; it is unclear at which
traumatic memories develop the typically fixed and irreconcilable quality with
174
• ADAPTATIONS TO 1T1AUJ\;\A
the associated sense of retraumatization often experienced in PTSD. The in­
flexihk quality nfthe:;e tr:uun:lric memori,,:; rcprc,;cllls;1
issue ofineanillg (see Chapter
. A corolla!)1 of Lhis
the process that leads to the lHL"C[ of the ,l\oidaf1ce phenomena. One view i,
that they represent a defense modulating the emotions associated with the
intense trallmatic cognitions, and thllS arc an integr;11
or the imrnediarc
trauma response
t, 1
Liudcuj,,)llt, 1Di4;
. HuwC\·C1.
Shalev (l ~9:2) found in a slud}, of terrorist attack victims
not proportional to intrusions in the immediate post attack period. It appeared
that avoidance only elllerged after an individual was ullable to work
these phenomena, These findings are in pan supported by other work
(Solomon et
1~)87b; McFarlane,
, which has suggested (I) that intrll­
sions ,lre com mOil to many who have experienced tr<Hlmatic events alld not
specific to PTSD; and (2) that avoidance is a phenomenon [hat emerges dur­
ing the monrh~ after the trauma and i" characteristic ofh;\\'illg
disorder, rather Lhall ufhavll1g been exposed LO a potentially traumatic stressor.
Very few prospective accounts have systematically examined survivors ill
hnmediate aftermath and examined the relationship between immediate
,reactions and subsequent emergence of PTSD. Such studies are likely to pro­
vide criLical eviciellce about the range of acute stress I-espouses and their rela­
I tionship to PTSD and the other psychiatric disorders that emerge in the set­
i;;,; tin:~ of trauma. A systematic study of train drivers involved in railway accidems
!'(Malt et aI., 1993) found that whereas more than half reported moderate to
jih.ighlevels of intrusive memories in the immediate aftermath, fewer than one­
:;~t?ini reported symptoms of acute psychophysiological arousal. Avoidance wils
f~~~cop1mon. The correlations between the various measures i~creased progres­
i slvelyat 1 month and 1 year,
that the relatIOnshIps among these
phenomena change with the passage of lime.
The suggestion that initial levels of intrusion and avoidance do not pr~dict
f:;:the onset ofPTSD point'> to the role of some other process, such as the destabi­
Ilization of an individual's normal pattern of arousal, which will have a feedback
I::;;fr·(f'$'
!'/eff'ect on the processing of thoughts and feelings (Shakv, 1992). Thus the focus
'on a cognitive processing- model, which underpins the current conceplllalization
of PTSD, may ha\'e hampered the investigation of what differemiat.es
'from maladaptive responses to trauma. As such, it may have diverteel attention
away f.-om the
of I r<llllIl<l on per~onality
0),
l".
i .,
~~silience <:tt t~}.~, "'tiG\e l)(
Resilience. Vulnerability. and Course
II
ft !'
l
'L,
•
175
In
action will be immediate fear, with little chance for
'. ;UilllS uf
sc\.u;tl ;:}Jllse IIU)" llave SUlIiC <"l'por'\lnit>, It. llll­
strategies to cope with the trauma. Therefore, the issue
of rc,ilielJ', at the time of the traullla is more of a concern wiTh prolonged or
recurrellt traumas in which victims are required to contain their fear and
arow:111 How('ver, with accident \'ictims who sU:;lain si,rniflGl11t in;l1rics. it
uf c rescue
outcome as the trauma itself.
are a s . .
.
A second issue relates to an individual's emotional reaction at the time of
the trauma. This point lS discussed at length in this book
Chapters 7 and
, but it should suffice to say that people who dissociate at the tiIlle of the
trauma are more vulnerable to posttraumatic reactions. However, it is impor­
tant to emphasize that many individuals who develop PTSO do not dissociate
at the time of the trauma, Dissociation also demonstrates the complexity of
the ddcrtllinalHs of vulllerability, The probability and severity of a dissocia­
tive respunse at the time of the trauma will be intluenced by the duration and
of the exposure, as well as by tile illdividual's personality, prior his­
tory of traumatization, and behavior triggered by the dissociation. Thus, the
issue of resilience relates both to the behavior and the mental slate of the in­
dividual at the tillle of the trauma.
The role of training in preventing PTSD is discussed by Ursano, Grieger,
and McCarroll in Chapter 19. The emotional impact of a traumatic event can
be subsramially modified
preparatiun and training. The sense of helpless­
ness is lessened as the individual gains an understanding of the behaviors that
will aid in sun'ival. Furthermore, the intensity of the exposure and the
of the danger may be modified by the use oflearned adaptive behaviors dur­
ing the emergency, whether these are methods of
and managing being
tortured, or ways of averting the dallgers of assault or rape in particular setTraining and leadership are obviously critical issues in the military and
emergency services.
Adaptations to Chronic Symptoms
the illdividual's capacity to cope with them is
Once ,ymptoll1s have
hehavior documented in PTSn sufferers tells
critical. A.s it stands. the
liS more about how
cope with the distress of their sympwnls than how
tratlIll;1 itself Lazarlls and Folklllan (
(He
The nature of the trauma allll1.he sliategies IL,<;;d tu cope Wilh it IIld)' \'ary sub­
stantially among different types of traumatic events. For example, in a motor
v~hicle accident the trauma probably has a very brief duration, and its ability
()~affect an individual eventual outcome may be minimal. The emotional re-
evaluatioH or how II! uch uric is harmed, threa1.,:Jled, and
~, perience, and by the evaluation of one's percieved options for mitigating the effects of the event. Tbus, it is important to consider resilience and vulner­ ability in terms of both individuals' responses to the trauma and their capac­
176 •
ADAPTATIONS TO TRAUA1A
Resilience, Vulnerability, and Course
ity to cope with their reactions. To
little r("search :1ttention.
this issue has received
The distress ofa psychological disorder can create the same sense of power­
lessness and the same threat of clisin
that cunfrorll the victims of
trauma. The comparative in tensity of the distress caused by the experience of
the trauma and that c:msed by rhe experience of s;!lnptoms desfTibec! Iw
British
iC
\\"llU ',dS" ,'cl<':l~lll ofLltc' Falklands \\(d{ ,\lId 'uhs('­
developed PTSD (l-:lughcs, 1
, I lughes describes his experience in
a graphic manner:
l~or no obvious reason I had '''UUCll', ueen overWtlelmed .by a crescendo of
blind unreasoning fear,
all
,md
... nothing that Gen.
eral Galticri', men had generated
with the teITor." tlUI ma)' own
mind invented that
Having louked death full in the eye on a willd.:
swept isthmus outside Goose (:reen :lnd
bllt two weeks later, on a
harrcn hill,idc called 'Wireless Ridge. I think I can honestly say! no longel'
feared dealh ur the thillg, real alld iHiagined thal usually become the ob­
of phobias. I was afraid thal night of t.he only thing thal could still
frighten me, myself. I was terrified oflosing my control. (I
p,1'!76)
Several studies have clcmOnSlT,lu.:;d that paticllLS I'lho h,\\t; been
can develop symptoms iden tical to PTSD in response to their illness (McGorry
~etal., 1991; Shaner & Eth,
1991), Such findings lead one to question the
that the experience of chronic PTSn itself has on the course of the dis
'. r. In contrast to the actual trauma, which is a circumscribed experience,
esymptoms ofPTSD (e.g"the intense flashbacks and nightmares) can
,~,,9-dless. The sufferer has to cope with the constant and unpredictable recur­
' renee of the memory of the tl'auma, with little anticipation of relief. Thus,
although the realistic danger of the trauma is long gone, continuing feelings
threat and fear are the emotional reality. These intrl1sions take away any
of security or safety of retreat in the privacy of one's mind, and result in
repeated traumatization. This is what leads to the disorder we call PTSD.
those who develop the disorder, the internal sense of threat and loss of
control may present a ne\v dimension of trauma. The attributes and
of the incllvidual t.hat allow him or her to tolerate anc! modnlate this distress
are the critical '
outcome of the persoll's
Orthe
who suffer from PTSn ,lfC ,Ie! I tally
the conseq\lences of the ~CCO\l
effecls of rhe disorder. which inclll(le
appraisal of the
the
(,f
\,/1
tl i clr~t\\'~d
aIld anhedonia
l LDCUJ 12.CHfllS­
lIle,[!!
that. the
that are critical to the individual's sense of identity and
';;~J!";!·.'~Y also be threatened and undermined by the PTSD sufferer's pattern of
to his or her symptoms. The very attachments that can provide a
•
177
powerful motivation for survival in the face of extreme threat can themselves
responses. The cli~rnrb:'lnr("s nfattention ~md
concentration mean that the person is no
able to interact witii his or
her current environment wilh tbe same sense of involH:ment. Even
activities such as reading, participating in a conversation, and watching televi­
demand
effon. It is this sense of
(l:1maged, rather t.han the
i lllilWdia[t' horro r ur lht: tr,lllllla, tin LlJ laf! y "iuim" ,!es,,',lx
the \\'or" t. :~~tJC:ct
of their ordeal in the
tenll.
he thn',ltel1ed by these sn. II
fit
t
I
i
CONCLUSION
From bis more general reviewoflongitudinal research into
Blank (1
concluded that it is dangerous to generalize about the course ofIYl'SD, as there
appears to be significClllt variation among individuals, traumatic e\'(:llts, and the
contexts in which events occur. Ultimately, answers to the many questiolls that
still exist will only emerge with sophisticated prospective studies that
the interaction between the effects of traumatic event, and the other VlIlner­
ability factors that influence the onset and course of psychiatric disorders in other
The important isstle to emphasize is that both the type of outcomes
and the enduring effects of tr:lUma vary widely. The critical question yet to be
answered is whether treatments that lead to a decrease in symptoms alter the
consequences of (raullla. Of paramount importance is the need to
demonstrate the effectiveness of preventive interventions, because the chronic
effects of trauma have important implications for public health.
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