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Advanced Psychopathology - PSYC961: Kangas, 2007 ©
Trauma & Posttraumatic Stress Disorder (PTSD):
Classification, Assessment & Theories
 Historical Terms: Nostalgia, shellshock, combat neurosis,
& combat fatigue.
 DSM-I: ‘gross stress reaction’ category
‘individual has been exposed to severe physical demands or
extreme emotional stress such as in combat or civilian
catastrophe (fire, earthquake, explosion etc)’.
 DSM-II: no pathological stress category
 1980 – DSM III: Posttraumatic Stress Disorder (PTSD).
“ stressor that would evoke significant symptoms of distress in
almost everyone”
[American Psychiatric Association (APA),1980,p.238]
DSM Classification
 1987 – DSM IIIR: PTSD Criterion A
“ an event that is outside the range of normal human experience
and that would be markedly distressing to almost anyone ”
1994 – DSM-IV PTSD Criterion A -
“the person experienced, witnessed, or was confronted with an
event or events that involved actual threatened death or serious
injury, or a threat to the physical integrity of self or others”,
and which evoked “intense fear, helplessness, or horror”
(APA), 1994,p.427)
DSM IV: PTSD Criteria (1)
 Defined by 3 central criteria:1. Re-experiencing - (one or more symptoms)
(a) recurrent and intrusive distressing recollections of the event,
including images, thoughts, & perceptions.
(b) recurrent distressing dreams of the event. (nightmares).
(c) reliving the experience, illusions, hallucinations & dissociative
flashback episodes.
(d) intense distress as exposure to internal/external traumacues.
(e) physiological reactivity on exposure to internal/ external cues.
DSM IV: PTSD Criteria (2)
2. Marked Avoidance and Emotional Numbing
- (three or more symptoms)
(a) avoid thoughts, feelings & conversations assoc. with trauma.
(b) avoid activities people, places that arouse trauma recollection.
(c) traumatic amnesia – inability to recall aspect/s of trauma.
(d) withdrawal from activities, interests etc.
(e) detachment or estrangement from others.
(f) restricted range of affect – blunted affect.
(g) sense of foreshortened future.
DSM IV: PTSD Criteria (3)
3. Physiological Arousal – (two or more symptoms)
(a) sleep disturbances
(b) irritability & anger outbursts
(c) concentration problems
(d) hypervigilance
(e) exaggerated startle response
Duration of at least one month post-trauma [Criterion E]
Acute: symptoms < than 3 months
Chronic: symptoms > than 3 months
delayed onset: symptoms occur at least 6 mths post-trauma event.
Causes clinically significant distress or impairment
[Criterion F]
DSM IV: Acute Stress Disorder (ASD)
 New diagnostic criteria
 Predictor of PTSD - provides opportunity for early intervention
 Defined by 4 criteria:- central emphasis on dissociative symptoms:
 emotional numbing
 reduced awareness of environment
 derealization
 depersonalization
 dissociative amnesia
 Duration: Occurs within 2 days and 4 weeks post-traumatic event.
Will ASD be retained in DSM V?
 Heavy emphasis on dissociative symptoms unsubstantiated
- BUT (a) Dissociation is neither necessary for PTSD,
(b) nor optimal predictor of PTSD
 The ASD diagnosis lacks empirical support:
- a substantial number of people develop PTSD without ASD
 Suggest delete ASD: add V code to PTSD
[Refs Bryant, 2007; Spitzer, First & Wakefield, 2007]
Current Controversy with PTSD Criteria
 ‘Conceptual bracket creeping’
(McNally, 2007)
 call for tightening definition of trauma in PTSD
(Spitzer, First & Wakefield, 2007)
 heavier emphasis on ‘directly experience’ versus ‘confronted’
 Non-specificity of PTSD syndrome (Spitzer et al., 2007)
 Criterion A is essential vs. other anxiety and mood disorders
 Emphasis on re-experiencing symptoms
 Eliminate somatic symptoms that overlap with other disorders
 Criteria C and D integrated into one cluster
RISK FACTORS INFLUENCING SEVERITY OF
TRAUMATIC STRESS RESPONSES (1)
 Exposure to a trauma is necessary but NOT sufficient to induce
PTSD/trauma responses.
 Lifetime prevalence rates: 4% - 12% (Kilpatrick, 1992; Resnick et al., 1993)
 National (US) study: 8% (Kessler et al., 1995, 2005).
 Important NOT to pathologize normal, transient stress responses
in the immediate aftermath of a traumatic event.
 fear, shock, disbelief, sadness, feelings of loss, grief.
 Pre-trauma:
 Female Gender
 personal & family psychiatric history (esp. anxiety & mood).
 adverse childhood experiences
 lower intelligence/ lack of education
 prior trauma exposure
RISK FACTORS INFLUENCING SEVERITY OF
TRAUMATIC STRESS RESPONSES (2)
 Peri-traumatic experiences:
 dissociative responses
 elevated heart rate/ physiological indicators (hyperarousal)
 subjective appraisals
 trauma severity
 younger age
 Post-Trauma:
 quality of social support.
 additional life stress
 coping strategies
 cultural attitudes.
NB: Heterogeneity of responses between individuals & type of
trauma (e.g., military vs. civilian events vs. disease related
events)
PREDICTORS OF PTSD: Empirical Evidence
 Meta-analytic reviews:
(1) Ozer, Best, Lipsey, & Weiss (2003)
 peri-traumatic dissociation (weighted r = .35)
 perceived support post-trauma (r = -.28)
 peritraumatic emotions (r = .26)
 perceived life threat peri-trauma (r =.26)
 family history of psychopathology ( r = .17)
 prior trauma (r =.17)
 prior adjustment (r=.17)
Meta-analytic Reviews (2)
(2) Brewin, Andrews, & Valentine (2000)
(a) Civilian studies:
 Life stress (r = .36)
 Poor social support ( r=.30)
 Trauma severity (r =.18)
 Low SES ( r =.15)
 Female gender; family psychiatric history, childhood adversity
(r =.13)
 Psychiatric history & previous trauma ( r =.11)
(b) Military Studies:
 Poor social support ( r =.43)
 Life stress (r =.31)
 Adverse childhood events ( r =.27)
 Trauma severity ( r =.26)
 Childhood abuse ( r =.25)
 Low intelligence ( r =.18)
 Lack of education (r =.15)
Comorbidity (& Differential) Diagnostic Issues
 Common Comorbid conditions associated with PTSD:
 Depression (suicide risk)
 Other forms of anxiety (esp. Panic Disorder)
 Substance Abuse (alcohol & drugs)
 Severe cases: Personality Disorders & aggression
 Common symptoms:
 guilt
 shame/ humiliation
 anger
 de-moralisation/ “mental defeat” (Ehlers & Clark, 2000)
 grief
Assessment Issues & Considerations (1)
 material covered may be distressing.
 inform client that assessment and initial stages of therapy may
exacerbate symptoms
 pivotal to ‘normalize’ trauma experience
 Clinician’s role – establish rapport, trust, supportive & safe
environment.
Assessment Issues (2)
 Distinguish b/w acute (ASD) and chronic trauma (PTSD)
* Reference source for following assessment considerations: Bryant & Harvey, 2000.
1. Motivation:
* Self-referred vs. coerced via others;
2. Organisational Issues:
* need to be aware of organizational structure & attitudes
of subculture.
Assessment Issues (3)
3. The Assessment Context/Environment:
* may activate trauma-cues or may be construed as safe
– hence exaggerate vs. downplay trauma symptoms.
4. Ongoing Stressors:
* Common secondary stressors
= physical injury, pain, loss (financial), & legal procedures.
* Need for comprehensive assessment to index all ongoing
stressors post-trauma.
Assessment Issues (4)
5. Previous Trauma & Psychiatric History:
“Even those seeking mental-health treatment may not recognize
the relevance of past trauma to their present problems and will
NOT discuss their trauma history unless explicitly asked to”
(Solomon & Johnson, 2002, p.957).
6. Comorbidity:
* especially depression;
* other anxiety, substance-abuse, & somatoform disorders;
* Suicide risk assessment is critical at initial assessment.
Assessment Issues (5)
7. Dissociative & Avoidance Symptoms:
 coping mechanisms:
E.g., distraction, thought suppression, medication, ‘safety
behaviours”, ritualistic behaviours (i.e., mantras)
8. Timing of assessment:
*time elapsed since trauma;
*determine if trauma-event & 2ndary stressors have ceased;
9. Meaning of trauma:
* client’s meaning of traumatic experience;
Assessment Issues (6)
10. Social Support:
* current availability – quality of support;
11. Additional considerations:
(a) current medications (sleeping, anxiolytics, anti-depressants);
(b) alcohol & drug use – current & previous history;
(c) legal procedures pending.
(d) malingering
Assessment Measures (1)
A. Acute Stress Disorder (ASD) Measures:
1. Structured Interviews:
(a) Acute Stress Disorder Interview (ASDI: Bryant, Harvey,
Dang & Sackville, 1998) – validated against DSM-IV criteria.
2. Self-Report Measures:
(a) Stanford Acute Stress Reaction Questionnaire (SASRQ:
Cardena, Koopman, Classen, Waelde, & Spiegel, 2000).
(b) Acute Stress Disorder Scale (ASDS: Bryant, Moulds, &
Guthrie, 2000).
Assessment Measures (2)
B. PTSD Measures:
1. Structured Interviews: Some well-validated measures
(a) Structured Clinical Interview for DSM-IV – PTSD Module
(Spitzer, Gibbon, & Williams, 1996).
(b) The Clinician Administered PTSD Scale (CAPS: Blake et al., 1995).
(c) The PTSD Symptom Scale Interview (PSS-I: Foa et al., 1993).
2. Self-Report Measures:
(a) Posttraumatic Diagnostic Scale (PTDS: Foa et al., 1997).
(b) Davidson Trauma Scale (DTS: Davidson et al., 1997).
(c) Mississippi Scale for Combat-Related PTSD
(Keane, Caddell, & Taylor, 1988).
(d) Impact of Events Scale – Revised Version
(IES-R: Weiss & Marmar, 1996) – NB *non-diagnostic*
Assessment Measures (3)
B. PTSD Measures - continued:
3. Dysfunctional Beliefs:
(a) Posttraumatic Cognitions Inventory (PTCI)
(Foa et al., 1999).
(b) World Assumptions Scale (WAS: Janoff-Bulman, 1989).
4. Additional Measures:
(a) Depression  BDI-II
(b) Dissociative Experiences Scale (Bernstein & Putnam, 1986)
(c) Distress  DASS; SCL-R90 or BSI;
TRAUMA THEORIES (1)
• Theories influence conceptualisation & approach to treatment.
1. Biological theories - Based on animal models
(i) Amygdala & Noradrenergic dysregulation
 hyperarousal symptoms
(i) Medial prefrontal cortex
- inhibition of amygdala by cortex  fear extinction
- PTSD: insufficient inhibition  re-experiencing symptoms
(iii) Hippocampal controversy: Does stress damage brain?
- cortisol (glucocorticoids)  learning and memory
- smaller hippocampi in PTSD patients  decline in memory
- BUT may be predisposing factor rather than stress-induced
TRAUMA THEORIES (2)
2. Schema-based theories:
(a) Horowitz’s stress response theory (1976,1986).
 New information (i) assimilated, or (ii) accommodated into
memory schemas
 Resolution requires oscillation between avoidance & intrusions
 Limitations of theory (Cf. Brewin & Holmes, 2003):
1. flashbacks vs. ordinary memories
2. does not explain peri-trauma reactions
3. successful recovery vs. successful avoidance.
TRAUMA THEORIES (3)
2(b). Janoff-Bulman’s Theory of Shattered Assumptions:
 3 common assumptions influencing processing of trauma:
(a) world is benevolent
(b) world is meaningful  reliable rules & principles of safety
(c) self is worthy  people are good, moral, well-intentioned.
TRAUMA THEORIES (4)
3. Behavioural - Conditioning Theory:
 Mowrer’s (1960) 2-factor learning theory
 neutral stimuli in trauma context acquire fear-eliciting
responses (CS) via association with the US.
- Repeated exposure  extinction
- BUT, extinction fails if use avoidance or distraction
 Strengths – (i) explains maintenance of symptoms,
(ii) central role of avoidance.
 Limitations – (i) absence of cognitive process;
(ii) does not differentiate between different anxiety
TRAUMA THEORIES (5)
4. Cognitive Models:
(a) Information – Processing Theories:
 Lang’s (1977) conceptual model of emotion:
- trauma memories represented by 3 types of propositional
information: (1) stimulus, (2) response, & (3) meaning.
 Edna Foa and her colleagues (1986, 1989, 1995)
- “Emotional processing theory”
- Trauma  formation of fear network.
- Trauma symptoms  network info incompatible with preexisting memory structures.
TRAUMA THEORIES (6)
[Foa et al’s theory – continued]
- Trauma Resolution:
(1) activation & emotional engagement of trauma memories;
(2) organization of trauma narratives; &
(3) correction of dysfunctional cognitions.
 Treatment implications: emphasis on exposure based procedures.
Strengths: (1) explains cognitive processes;
(2) associated with highly effective treatment approach.
Limitation: memory inhibition research vs. memory modification
TRAUMA THEORIES (7)
(b) Dual Representation Theory (Brewin et al., 1996).
- Trauma memories dissociated from ordinary memories.
- Hence dual memory symptoms operating in parallel.
(1) Verbally Accessible Memory (VAMs)
= oral or written narrative memories; deliberatively retrieved;
(2) Situationally Accessible Memories (SAMs)
= explain flashback experiences as SAMs triggered involuntarily
by situational trauma - cues.
TRAUMA THEORIES (8)
(b) Dual Representation Theory – [Continued]
 Implications of theory = PTSD is a hybrid disorder:
(1) resolution of negative cognitions
(2) management of flashbacks.
 Limitations:
1. Controversial – no compelling evidence of fragmented VAMS
2. Heavy focus on flashbacks – no explanation for more common
PTSD symptoms
3. No conclusive evidence that SAMs NOT stored in VAMs system
 minimal info (thus evidence) on how 2 systems interact
TRAUMA THEORIES (9)
(c) Ehler & Clark’s (2000) Cognitive Model:
(a) Traumatized individuals focus on data-driven/sensory processing
vs. conceptual driven processing
(b) Associated with autobiographical memory deficits
 lack contextualisation & poor elaboration
(c) Excessive negative appraisals
(d) Maladaptive coping strategies
TRAUMA THEORIES (10)
(c) Ehler & Clark’s (2000) Cognitive Model - conmtinued:
* Limitations (cf: Taylor, 2006):
(a) less parsimonious than other cog-behav models
(b) Questionable proposition – emphasis on data-driven processes
(c) Does not explain role of numbing and dissociative symptoms
(d) Does not explain why only a small proportion of people exposed
to life threat events develop PTSD
Common Treatment Interventions for Trauma
A. Psychological Debriefing/ Crisis Intervention
B. Pharmacotherapy
C. Cognitive Behavioural Therapy (CBT) Approaches:
(1) Exposure Therapies:
(a) Systematic Desensitization
(b) Prolonged Imaginal and Invivo Exposure
(2) Combined Approaches:
(a) Exposure and Cognitive Therapy
(b) Cognitive Processing Therapy (CPT: Resick & Schnicke, 1992)
(3) Anxiety/Stress Management Programs
(4) Eye Movement Desensitization & Processing (EMDR)
D. Psychodynamic Therapies
E. Integrative Approaches.
Common Treatment Interventions for Trauma (II)
 Empirically supported treatments for PTSD & recommended by the
International Society for Traumatic Stress Studies (ISTSS):
 CBT:
 Foa et al’s PE (exposure) therapy
 Cognitive therapy (e.g., Resick et al., 2002)
 Interpersonal psychotherapy (e.g., Bleberg & Markowitz, 2005)
 Minimal evidence base for psychodynamic & supportive
counselling
[Ref: Nemeroff et al., 2006]
REFERENCES
Blake, D. D., Weathers, F. W., Nagy, L. et al. (1995). The development of a clinician administered PTSD scale. Journal of
Traumatic Stress, 8, 75-90.
Brewin, C.R., Andrews, B., & Valentine, J.D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in traumaexposed adults. Journal of Consulting and Clinical Psychology, 68, 748-766.
Brewin, C.R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological
Review, 103, 670-686.
Bryant, R.A. (2007). Does dissociation further our understanding of PTSD? Journal of Anxiety Disorder,
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Psychological Association.
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structured clinical interview. Psychological Assessment, 10, 215-220.
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