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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 • 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. 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