Assessing long-term effects of trauma: diagnosing symptoms of avoidance and numbing.

OBJECTIVE: This study compared the discovery of posttraumatic stress disorder (PTSD) symptoms by means of the Structured Clinical Interview for DSM-III-R (SCID) with a semistructured, psychodynamic clinical interview in a long-term follow-up of the survivors of the Buffalo Creek (W.Va.) flood. METHOD: Videotaped semistructured, psychodynamic clinical interviews of a small group of survivors (N=6) were compared with the results obtained in a prior group-level SCID investigation. RESULTS: Seventy-two percent of the total PTSD symptoms for the subjects studied were elicited exclusively by the psychodynamic clinical interview. PTSD cluster C symptoms of avoidance and numbing of general responsiveness were especially sensitive to discovery by this method. CONCLUSIONS: The psychodynamic clinical interview should be included in the design of studies that seek to investigate long-term effects of trauma, which are especially likely to be manifest in negative symptoms and subtle character change.

Post-traumatic stress disorder in victims of disasters.

Disasters can produce significant, lasting psychological sequelae. Much of the disaster work that mental health professionals can do falls outside of the more traditional roles usually taken by mental health professionals. These roles include reaching out to survivors through a variety of modes and rarely waiting for them to seek traditional forms of help. Much of what can be done does not require labeling individuals as disordered but may be done within the overall response of the community to the survivors on a variety of levels. To be most effective, we need to be involved in planning efforts that can be activated when disaster strikes, rather than being reactive to the situation after it has occurred. The potential range of responses can challenge the professional who wants to help his or her community when it has been affected.

The comorbidity of post-traumatic stress disorder and suicidality in Vietnam veterans.

Vietnam veterans (N = 232) recruited from three sources were assessed for suicidal thinking and behaviors, and symptoms of posttraumatic stress disorder (PTSD) and depression. Findings support the notion that suicidal thoughts are prevalent in this group, with veterans in psychotherapy reporting a greater likelihood of such symptoms (82.6%) than veterans in the community (35.7%) or those seeking assistance through a veteran's outreach center (66.7%). Thoughts of ending one's life and a previous suicide attempt were significantly correlated with a diagnosis of PTSD (r = .53, p < .001; and r = .33, p < .001, respectively). Veterans with a diagnosis of PTSD and depression or dysthymia were also more likely to report suicidal thinking and behaviors than veterans with only one of the diagnoses.

Portraits of survival. A twenty-year follow-up of the children of Buffalo Creek.

This study is a follow-up of the children of Buffalo Creek "hollow" who survived the dam collapse and flood of 1972. It was conceived as a complement to the 1988 NIMH-funded follow-up investigation of the children of Buffalo Creek conducted by the University of Cincinnati Traumatic Stress Study Center. That 1988 study utilized standardized methodology to assess levels of psychopathology present among those who were children at the time of the 1972 flood. Among the original child subjects, results demonstrated that the rates of both posttraumatic stress disorder (PTSD) and levels of other psychopathology had sharply declined as the children moved to adulthood. Several questions remained unanswered: the long-term meaning which the flood had in the survivors' lives and its impact on their adaptation as they progressed through the subsequent stages of emotional development. For these reasons, we, as psychoanalytic investigators who had been members of the original clinical assessment team, planned an interview of child and adolescent survivors as a follow-up to our interviews in 1974 with a particular focus on meaning and adaptation.

Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample.

Research has indicated significant comorbid psychopathology with chronic posttraumatic stress disorder (PTSD) in samples of war veterans. The present paper examines the issue of comorbidity in a disaster sample to learn whether findings from veterans generalized to this event. A total of 193 subjects exposed to the Buffalo Creek dam collapse of 1972 were examined 14 years later using diagnoses derived from the Structured Clinical Interview for DSM-III (SCID). Past and present PTSD was found in a significant portion of the sample. Major depression was the next most common diagnosis and was highly related to PTSD. Anxiety disorders were also common. The overlap with other diagnoses was quite similar to that found in a sample of Vietnam veterans we studied earlier, except that the disaster sample had fewer dysthymic disorders, substance abusers, and antisocial personality disorders. Possible explanations for comorbidity in chronic PTSD were discussed and it was suggested that the morphology of PTSD may be quite stable in at least some other nonveteran trauma populations.

Somatic reenactment in the treatment of posttraumatic stress disorder.

Somatic reenactments, like other intrusive symptoms in post-traumatic stress disorder, such as flashbacks and nightmares, reproduce the mental content of traumatic events. Four cases are presented from survivors of military trauma and civilian catastrophes. The patients were part of larger research projects carried out by the University of Cincinnati Traumatic Stress Study Center. Understanding such symptoms as repetitions of the trauma itself proved useful therapeutically, especially in consolidating the working alliance.

Risk factors for PTSD and other diagnoses in a general sample of Vietnam veterans.

This study examined the contribution of premilitary, military, and postmilitary risk factors to posttraumatic stress disorder (PTSD) and other postwar diagnoses in a sample of Vietnam veterans. PTSD was explained primarily by war stressors, including threat to life and exposure to grotesque death, but premilitary and postmilitary factors also contributed to the likelihood of a current diagnosis of PTSD. Panic disorder was also highly predicted by war experiences, whereas prewar functioning played a stronger role in several non-PTSD diagnoses. The study supported the notion that PTSD is specifically linked to intense stressors. Mechanisms for interactions among risk factors are discussed.

Buffalo Creek survivors in the second decade: stability of stress symptoms.

A follow-up study of 120 adult survivors of the Buffalo Creek dam collapse of 1972 showed group changes 14 years after the event. Decreased symptoms were noted in all areas, although significant psychopathology remained in about one-quarter of the survivors. A small group with delayed onset of symptoms was identified.

Multiple diagnosis in posttraumatic stress disorder. The role of war stressors.

Prior studies have shown that posttraumatic stress disorder (PTSD) in Vietnam veterans is associated with various aspects of war stressors and that other diagnoses often co-occur with PTSD in this population. The present report examines the prediction of other diagnoses, in combination with PTSD, from a variety of war stressor experiences in a broad sample of veterans recruited from clinical and nonclinical sources. The results show that PTSD with panic disorder is better explained by war stressors than other diagnostic combinations and that high-risk assignments and exposure to grotesque deaths were more salient than other stressor experiences in accounting for different diagnostic combinations. Implications of the findings for PTSD's placement in the DSM-III-R and for psychological and pharmacological treatments were discussed.

Posttraumatic stress disorder. Toward DSM-IV.

This report raises conceptual issues about the validity of the posttraumatic stress disorder diagnosis as described in DSM-III. The helpfulness of DSM-III is acknowledged, but gaps in that classification are noted. These are organized into three areas: the etiology of the disorder, its natural history, and diagnostic specificity. Suggestions are made for conceptualizing these issues and for research that needs to be undertaken to help resolve them. The authors urge more theoretical and empirical attention to these important issues in the upcoming years, so that later diagnostic descriptions and understandings will be more precise.

Psychotherapy with survivors of the Beverly Hills Supper Club fire.

Thirty psychotherapies with survivors of a devastating supper club fire were studied. Treatments were judged in terms of level of completeness, traumatic symptomatology, therapist experience, and therapist sensitivity to the particular disaster influenced level of completion. Nodal points, such as engagement, dosage of affect, and management of transference are described, and case illustrations provided.

The internship: some disquieting findings.

A natural experiment in psychiatric education took place nationally between 1970 and 1976, when one group of residents entered psychiatry with an internship, and the other without one. In this study 22 psychiatry residents with an internship and 25 without one were compared during their first two years of training. Initial faculty evaluations of the two groups' responsibility, insight, teachability, and knowledge were virtually identical, as were those of their overall performance in inpatient, consultation, and emergency psychiatry. However, ratings of outpatient psychotherapy showed several significant and differences favoring the noninternship group. The authors find these results disquieting. They suggest that interferences with empathy may be an untoward side effect of the internship.