Stress and AdjustmentDisorders

WHAT IS STRESS?Categories of StressorsFactors Predisposing a Person to StressCoping with Stress

THE EFFECTS OF SEVERE STRESSBiological Effects of StressPsychological Effects of Long- Term Stress

ADJUSTMENT DISORDER: REACTIONS TOCOMMON LIFE STRESSORSAdjustment Disorder Caused by UnemploymentAdjustment Disorder Caused by BereavementAdjustment Disorder Caused by Divorce or

Separation

POST· TRAUMATIC STRESS DISORDER:REACTIONS TO CATASTROPHIC EVENTSPrevalence of PTSD in the General Population

Distinguishing between Acute Stress Disorderand Post- Traumatic Stress

The Trauma of RapeThe Trauma of Military CombatSevere Threats to Personal Safety and SecurityCausal Factors in Post- Traumatic StressLong- Term Effects of Post -Traumatic Stress

PREVENTION AND TREATMENT OFSTRESS DISORDERSPrevention of Stress DisordersTreatment for Stress DisordersChallenges in Studying Crisis VictimsWhat We Are Learning about Crisis Intervention

UNRESOLVED ISSUES:Psychotropic Medication in the

Treatment of PTSD

ife can be stressful. Everyone faces a different mix of demands and adjustments in life, andanyone of us may break down if the going gets tough enough. Under conditions of over-whelming stress, even a previously stable person may develop temporary (transient) psy-chological problems and lose the capacity to gain pleasure from life (Berenbaum & Connelly,1993). This breakdown may be sudden, as in the case of a person who has gone through asevere accident or fire, or it may be gradual, as in the case of a person who, in a deterio-rating marriage or other intimate relationship, has been subjected to prolonged periods oftension and challenges to his or her self-esteem. Most often the individual recovers oncethe stressful situation is over, although in some cases there may be long-lasting damage toself-concept and an increased vulnerability to certain types of stressors (Resick, 2001).

Today's stress can be tomorrow's vulnerability. In the case of a person who is quite vulner-able to begin with, of course, a stressful situation may precipitate more serious and lastingpsychopathology.

demands as stressors, to the effects they create within anorganism as stress, and to efforts to deal with stress ascoping strategies. Stress is a by-product of poor or inade-quate coping.

All situations, positive and negative, that requireadjustment can be stressful. Thus, according to Canadianphysiologist Hans Selye (1956, 1976a), the notion of stresscan be broken down further into eustress (positive stress)and distress (negative stress). (In most cases, the stressexperienced during a wedding would be eustress; duringa funeral, distress.) Both types of stress tax a person'sresources and coping skills, although distress typically hasthe potential to do more damage.

Research findings and clinicalobservations on the relationshipbetween stress and psychopathol-ogy are so substantial that the roleof stressors in symptom develop-ment is now formally emphasizedin diagnostic formulations. InDSM -IV-TR (American PsychiatricAssociation, 2000), for example, adiagnostician can specify on AxisIV the specific psychosocial stres-sors facing a person. The Axis IVscale is particularly useful in rela-tion to three Axis I categories:adjustment disorder, acute stressdisorder, and post-traumatic stressdisorder (acute, chronic, ordelayed). These disorders involvepatterns of psychological andbehavioral disturbances that occurin response to identifiable stressors.The key differences among them lienot only in the severity of the distur-

____ WHAT Is STRESS?

Life would be simple indeed if all of our needs were auto-matically satisfied. In reality, however, many obstacles,both personal and environmental, prevent this ideal situa-tion. We may be too short for professional basketball orhave less money than we need. Such obstacles place adjus-tive demands on us and can lead to stress. The term stresshas typically been used to refer both to the adjustivedemands placed on an organism and to the organism'sinternal biological and psychological responses to suchdemands. To avoid confusion, we will refer to adjustive

Stress can result from both negative and positive events-distress (negative stress) from tragiccircumstances found in events such as funerals and eustress (positive stress) found in events likeweddings. Both types of stress can tax a person's resources and coping skills, a/though distress typicallyhas the potential to do more damage.

bances but also in the nature of the stressors and the timeframe during which the disorders occur (Cardefia, Butler,& Spiegel, 2003). In these disorders, the stressors suppos-edly can be identified as causal factors and specified onAxis IV.

Categories of StressorsAdjustive demands, or stressors, stem from sources that fallinto three basic categories: (1) frustrations, (2) conflicts,and (3) pressures. Although we will consider these cate-gories separately, they are closely related.

FRUSTRATIONS A wide range of obstacles, both exter-nal and internal, can lead to frustration (see Penk,Drebing, & Schutt, 2002, for a discussion of PTSD in theworkplace). Prejudice and discrimination, unfulfillment ina job, and the death of a loved one are common frustra-tions stemming from the environment; physical handi-caps, limited ability to perform certain tasks, loneliness,guilt, and inadequate self-control are sources of frustrationbased on personal limitations. Frustrations can be particu-larly difficult for a person to cope with because they oftenlead to self-devaluation, making the person feel that she orhe has failed in some way or is incompetent.

CONFLICTS In many instances, stress results from thesimultaneous occurrence of two or more incompatibleneeds or motives: The requirements of one preclude satis-faction of the others. For example, if a woman is committedto a career but must decide whether to uproot her family fora promotion or decline it and leave her family undisturbed,she will experience conflict while trying to make the choice.Conflicts with which everyone has to cope may be classifiedas approach-avoidance, double-approach, and double-avoidance types (see Table 5.l). Classifying conflicts in thismanner is somewhat arbitrary, and various combinationsamong the different types are perhaps the rule rather thanthe exception. Thus a double-approach conflict betweenalternative careers may also have approach-avoidanceaspects because of the responsibilities that either career willimpose. Regardless of how we categorize conflicts, they rep-resent a major source of stress that can often become over-whelmingly intense.

PRESSURES Stress may stem not only from frustrationsand conflicts but also from pressures to achieve specificgoals or to behave in particular ways. Pressures force us tospeed up, redouble our effort, or change the direction ofgoal-oriented behavior, which can seriously tax our copingresources or even lead to maladaptive behavior.

1. Approach-avoidance conflicts involve strongtendencies to approach and to avoid the samegoal. Mary has been offered an appealing newjob in another department of the company inwhich she is employed. The job is one that shehas had her eye on for several years andincludes a substantial pay raise and betterbenefits. Unfortunately, her ex-husband, withwhom she has been having great difficulty, alsoworks in that department. She becomes veryupset when she has to deal with him and isconcerned that the work atmosphere would beunbearable.

2. Double-approach conflicts involve choosingbetween two or more desirable goals. Althoughthe experience may cause more eustress thandistress, the stress is still real and the choicedifficult. In either case, the person gives upsomething. Charles G. is faced with a decisionthat many would envy but that is giving him a lotof sleepless nights. He has been admitted intotwo graduate programs that have almost equalappeal. One is a program at a highly prestigious

university whose graduates tend to get the bestpositions. The other school is also highlyrespected (though not as much as the firstschool) and has exactly the type of specializationhe has wanted, with an outstanding faculty.Choosing one, of course, means turning downthe other. He has been vacillating between thechoices, sometimes changing his decision every5 minutes.

3. Double-avoidance conflicts are those in which thechoices are between undesirable alternatives.Neither choice will bring satisfaction, so the taskis to decide which course of action will be leastdisagreeable-that is, the least stressful. Jenny'smother sent her an airline ticket to enable her toattend an "important" family outing the likesof which Jenny has grown to despise. She isconsidering a course of action that she findsvery distasteful-lying to her mother aboutbeing so busy that she cannot attend. She knowsthat her mother will be very punitive if she failsto go, but the family gatherings have becomevery stressful.

Pressures can originate from both external and inter-nal sources. For example, students may feel under severepressure to make good grades because their parentsdemand it (external pressure) and because they want to getinto graduate school (internal pressure). The long hours ofstudy, the tension of examinations, and the sustained con-centration of effort over many years result in considerablestress for many students. Many students preparing forimportant, career-determining examinations such as theGraduate Record Exam (GRE) or the Medical CollegeAdmissions Test (MCAT) experience considerable anxietyas the examination date approaches. Fifty premedical stu-dents reported their anxiety levels for 17 days before and17 days after the MCAT. The experience of anxiety wasgreater in the days preceding the examination, with peakanxiety occurring as the examination day approached(Bolger, 1990). People who were prone to dealing withstress by overusing defense mechanisms such as wishfulthinking or self-blame tended to show increased maladap-tive behavior and increased anxiety under high stress. Per-formance on the examination, however, did not appear tobe related to the use of various coping strategies to dealwith the stress; that is, those students who used maladap-tive behaviors did not appear to do worse on the exam.

Occupational demands can also be highly stressful,and many jobs make severe demands in terms of responsi-bility, time, and performance (Roberts & Levinson, 2001;Tennant, 2001). Although we have arbitrarily separatedstress into three categories, a given situation may involveelements of all three categories. The following case illus-trates this point:

A premed student whose lifelong ambition was to becomea doctor received rejection letters from all the medicalschools to which he had applied. This unexpected blowleft him feeling depressed and empty. He felt extreme frus-tration over his failure and great conflict over what his nextsteps should be. He was experiencing pressure from hisfamily and peers to try again, but he was also over-whelmed by a sense of failure. He felt so bitter that hewanted to drop everything and become a beach bum or ablackjack dealer in Las Vegas. The loss of self-esteem hewas experiencing left him with no realistic backup plansand little interest in pursuing alternative careers.

Although a particular stressor may predominate in anysituation, we rarely deal with an isolated demand. Instead,we usually confront a continuously changing pattern ofinterrelated and sometimes contradictory demands.

Factors Predisposing a Personto StressThe severity of stress is gauged by the degree to which itdisrupts functioning. The actual degree of disruption thatoccurs or is threatened to occur depends partly on a stres-sor's characteristics; partly on a person's resources, both

personal and situational, for meeting thedemands resulting from the stress; and partlyon the relationship between the two. Every-one faces a unique pattern of adjustivedemands. This is because people perceive andinterpret similar situations differently andalso because, objectively, no two people arefaced with exactly the same pattern of stres-sors. Some individuals are more highly resis-tant to developing long-term problems understress than others; that is, some individualsare more resilient as a result of personalitycharacteristics and background experiences.(For an informative discussion of resiliencyamong Holocaust survivors, see the recentarticle by de Vries and Suedfeld, 2005.)

Living in extreme poverty with insufficient life resources can be a pawerful stressarin a person's life at any age, but especially for children.

THE NATURE OF THE STRESSORAlthough most minor stressors, such as mis-placing one's keys, may be dealt with as a mat-ter of course, stressors that involve importantaspects of a person's life-such as the death ofa loved one, a divorce, a job loss, or a seriousillness-tend to be highly stressful for mostpeople. Furthermore, the longer a stressor

operates, the more severe its effects. Prolonged exhaustion,for example, imposes a more intense stress than temporaryfatigue. Also, stressors often appear to have a cumulativeeffect. A married couple may maintain amicable relationsthrough a long series of minor irritations or frustrations,only to dissolve the relationship in the face of "one laststraw" of a precipitating stressor. Sometimes key stressorsin a person's life center on a continuing, difficult life situa-tion (Tein, Sandler, & Zautra, 2000). These stressors areconsidered chronic, or long-lasting. A person may be frus-trated in a boring and unrewarding job from which there isseemingly no escape, suffer for years in an unhappy andconflict-filled marriage, or be severely frustrated by a phys-ical handicap or a long-term health problem.

Encountering a number of stressors at the same timealso makes a difference. If a man has a heart attack, loseshis job, and receives news that his son has been arrested forselling drugs, all at the same time, the resulting stress willbe more severe than if these events occurred separately.

Finally, the symptoms of stress intensify when a per-son is more closely involved in an immediately traumaticsituation. Pynoos and colleagues (1987) conducted anextensive investigation of children's symptoms and behav-ior 1 month after a shooting incident in a schoolyard(1 child was killed and several others wounded when asniper randomly fired into the playground). A total of 159children from the school were interviewed. Depending onwhere they were at the time of the shooting-on the play-ground, in the school, in the neighborhood, on the wayhome, absent from school, or out of the vicinity-the chil-dren experienced different stress levels. Children on theplayground, closest to the shooting, had the most severesymptoms, whereas children who were not at school dur-ing the shooting experienced no symptoms.

THE EXPERIENCE OF CRISIS From time to time, mostof us experience periods of especially acute (sudden andintense) stress. The term crisis is used to refer to timeswhen a stressful situation approaches or exceeds the adap-tive capacities of a person or group. Crises are often espe-cially stressful because the stressors are so potent that thecoping techniques we typically use do not work. Stress canbe distinguished from crisis in this way: A traumatic situa-tion or crisis overwhelms a person's ability to cope, whereasstress does not necessarily overwhelm the person.

A crisis or trauma may occur as a result of an acrimo-nious divorce, a natural disaster such as a flood (Waelde,Koopman, et al., 2001), or the aftermath of an injury or dis-ease that forces difficult readjustments in a person's self-concept and way of life. The outcome of such crises has aprofound influence on a person's subsequent adjustment. Ifa crisis leads a person to develop an effective new method ofcoping-perhaps joining a support group or accepting helpfrom friends-then he or she may emerge from the crisiseven better adjusted than before. But if the crisis impairsthe person's ability to cope with similar stressors in the

The trauma of sudden and powerful disasters can produce intensestress. These people are reacting to the collapse of the WorldTrade Towers.

future because of an expectation of failure, then his or heroverall adjustment will suffer. For this reason, crisis inter-vention (to be discussed below)-providing psychologicalhelp in times of severe and special stress-has become animportant element in contemporary treatment and pre-vention approaches (Arehart-Treichler, 2004).

LIFE CHANGES It is important to remember that lifechanges, even some positive ones such as winning a desiredpromotion or getting married, place new demands on usand thus may be stressful. Our psychosocial environments(including such things as our friendship networks, workrelationships, and social resources) can playa significantrole in causing disorders or precipitating their onset, evenin biological disorders such as bipolar disorder (see Chapter7; Johnson & Miller, 1997). The faster the changes, thegreater the stress. Early research efforts on life changesfocused on developing scales that could measure the rela-tionship between stress and possible physical and mentaldisorders. In one early attempt, Holmes and Rahe (1967),for example, developed the Social Readjustment RatingScale, an objective method for measuring the cumulativestress to which a person has been exposed over a period oftime (see also Buhler & Pagels, 2003). This scale measureslife stress in terms of life change units (LCU): The morestressful the event, the more LCUs assigned to it. At thehigh end of the scale, "death of a spouse" rates 100 LCUsand "divorce" rates 73 LCUs; at the low end of the scale,"vacation" rates 13 LCUs and "minor violations of the law"rates 11 LCUs. Holmes and his colleagues found that peo-ple with LCU scores of 300 or more for recent months wereat significant risk for getting a major illness within the next2 years. In another effort, Horowitz and his colleagues(1979) developed the Impact of Events Scale (see alsoShevlin, Hunt, & Robbins, 2000). This scale measures aperson's reaction to a stressful situation by first identifying

the stressor and then posing a series of questions to deter-mine how he or she is coping.

Although the use of life event scales in the assessmentof stress has shown promise (Gray, Litz, et al., 2004), thisapproach has been criticized for numerous methodologi-cal problems. For example, a number of criticisms havetargeted the items selected for different scales, the subjec-tivity of the scoring, the failure to take into account therelevance of items for the populations studied, and thereliance on subjects' memory of events (Monroe &Simons, 1991). Other limitations of life event scales is thatthey tend to measure chronic problems rather than reac-tions to specific environmental events (Depue & Monroe,1986; Monroe, Roberts, Kupfer, & Frank, 1996), and,depending on what mood the person is in, the scales' ratingof how stressful something is can vary. Perhaps the mostproblematic aspect of life event scales is that they serveonly as a general indicator of distress and do not provideuseful information about specific types of disorders.Despite the limitations of scales devised to measure lifestressors, however, the evidence supports the stressfulnessoflife changes (Maddi, Bartone, & Puccetti, 1987).

Another approach to the assessment of significant lifeevents that has received attention among researchers is theLife Event and Difficulty Schedule by Brown and Harris(1989) and Brown and Moran (1997). This approachinvolves a semistructured interview that places the lifeevent rating variables in a clearly defined context in orderto increase inter rater reliability. This approach makes itpossible to assess the meaning of the event to the individ-ual more directly. Although this approach is more labor-intensive and costly to administer, the resulting ratings areconsidered more reliable than those of other life eventapproaches.

A PERSON'S PERCEPTION OF THE STRESSOR Most ofus are well aware that in some cases, one person's stressor isanother person's thrill. Some look forward to a chance to beon stage; others dread it. The different reactions that peoplehave to environmental events are due inpart to the way they perceive the situa-tion-the same event will be interpreteddifferently by different people. A studyby Clark, Salkovskis, Ost, et al. (1997)found that persons who are prone tohaving panic attacks tend to interpretbody sensations in a more catastrophicway than patients who do not experiencepanic attacks. A person who feels over-whelmed and is concerned that he or shewill be unable to deal with a stressor ismore likely to experience panic in the sit-uation than a person who feels able tomanage it. For example, a mother who isoverwhelmed by the feeling that her three unruly childrenare unmanageable and leaves them unattended is more

likely to experience negative consequences than a similarlystressed mother who stays with them.

Often, new adjustive demands that have not beenanticipated (and for which no ready-made coping strate-gies are available) will place a person under severe stress. Adevastating house fire and the damage it brings are notoccurrences anyone has learned to cope with. Likewise,recovery from the stress created by major surgery can bemarkedly facilitated when a patient is given realistic expec-tations beforehand; knowing what to expect adds pre-dictability to the situation, which reduces stress andanxiety (Leventhal, Patrick-Muller, & Leventhal, 1998;MacDonald & Kuiper, 1983). Understanding the nature ofa stressful situation, preparing for it, and knowing howlong it will last all lessen the severity of the stress when itdoes come.

Perceiving some benefit from a disaster, such as grow-ing closer to your family because of a tragedy, can moder-ate the effects of a trauma somewhat and make adjustmentto the circumstances easier. In fact some theorists (e.g.,Christopher, 2004) have pointed out that trauma alwaysleaves the person transformed in some way and that onenatural outcome of the stress process is adaptation andgrowth. Of course, some stressors are more difficult toadapt to or accommodate than others. A study by McMil-lan, Smith, and Fisher (1997) found that an individual'sability to perceive some benefit in adapting to the conse-quences of a disaster depended in part on the nature of thedisaster itself. For example, it was much more difficult forvictims to perceive some "silver lining" from a tragic air-plane crash in which many people died than it was forthem to adapt to the damage from a tornado. In the case ofan airplane crash, no "benefit" can be found, whereas thetornado offers more opportunity: "It could have beenworse, the school might have been hit" or "Thank goodnessso many were off at work!"

THE INDIVIDUAL'S STRESS TOLERANCE People whodo not handle changing life circumstances well may be par-

ticularly vulnerable to the slightest frus-tration or pressure. Children areparticularly vulnerable to severe stres-sors such as war and terrorism (Petrovic,2004; Shaw, 2003). People who are gen-erally unsure of their adequacy andworth are much more likely to experi-ence threat than those who feel generallyconfident and secure. The term stresstolerance refers to a person's ability towithstand stress without becoming seri-ously impaired. People vary greatly inoverall vulnerability to stressors. Blan-chard, Hickling, Taylor, and Loos (1995)found that an individual's prior history

of major depression is a risk factor for the development ofsevere psychological symptoms related to stress after a

A risk factor is any variable thatincreases the likelihood ofa specific(and usually negative) outcomeoccurring at a later point in time. Forexample, obesity is a risk factor forheart disease; perfectionism is apersonality trait that is a risk factorfor eating disorders.

motor vehicle accident (see Chapter 7). Some individualsappear to be constitutionally more "frail" than others andtend to have more difficulty handling even relatively minorchange. They do not have much physical stamina and maybecome fatigued or sick in the face of stressful situations. Inaddition, different people are vulnerable to different stres-sors. They may have failed to learn effective adaptive strate-gies for certain kinds of stressors. An individual's learninghistory plays a crucial part in this general capacity to dealwith stress. Early traumatic experiences can leave a personespecially vulnerable to-or especially well equipped tohandle-certain stressors (see Chapter 3 for diathesis-stressmodels). Having a poor "track record" at handling difficultcircumstances leaves one vulnerable to new challenges. Forexample, a person who has been subjected to uncontrol-lable stressors (such as being sexually abused at an earlyage) tends to become vulnerable or highly sensitized to laterassault or abuse. For these and other reasons, emergenciesand disappointments that one person can take in stridemay prove incapacitating to another.

A LACK OF EXTERNAL RESOURCES AND SOCIAL SUP-PORTS Considerable evidence suggests that positivesocial and family relationships can moderate the effects ofstress on a person (Ozer, Best, et aI., 2004). Conversely, thelack of external supports, either personal or material, canmake a given stressor more potent and weaken a person'scapacity to cope with it. A nationwide survey of stressfullife events in mainland China found that problems withinterpersonal relationships were the most commonlyreported stressors in daily life (Zheng & Lin, 1994). Adivorce or the death of a mate evokes more stress if peopleare left feeling alone and unloved than if they are sur-rounded by people they care about and feel close to. Siegeland Kuykendall (1990), for example, found that widowed

men who attended church or temple experienced lessdepression than those who did not. This study also foundthat men who had lost a spouse were more often depressedthan women who had done so. The reasons for this findingremain unclear, although others have found similar results(e.g., Stroebe & Stroebe, 1983). It could be that the womenhad a closer network of friends from the outset, which mayhave reduced their vulnerability to depression (Kershner,Cohen, & Coyne, 1998).

In other situations, a person may be adversely affectedby family members who are experiencing problems. Thelevel of tension for all family members can be increased ifone member experiences extreme difficulty such as achronic or life-threatening illness or a psychiatric disabil-ity. A person whose spouse is experiencing psychologicaldisturbance is likely to experience more stress than onewhose spouse is psychologically better adjusted (Yager,Grant, & Bolus, 1984). The stress of the illness is com-pounded by the loss of support.

Often a culture offers specific rituals or courses ofaction that support people as they attempt to deal with cer-tain types of stress. For example, most religions providerituals that help the bereaved, and in some faiths, confes-sion and atonement help people deal with stresses relatedto guilt and self-recrimination.

Coping with StressSometimes inner factors such as a person's frame of refer-ence, motives, competencies, or stress tolerance play thedominant role in determining his or her coping strategies.For example, a person who has successfully handled adver-sity in the past may be better equipped to deal with similarproblems in the future (Masten & Coatsworth, 1998). (Seethe discussion on resilience in Bonanno, 2004; see also

Chapter 3.) At other times environmental conditions, suchas extreme social pressures, are of primary importance.Any stress reaction, of course, reflects the interplay of innerstrategies and outer conditions-somemore influential than others but all work-ing together to make the person react in acertain way. Ironically, some people createstress for themselves rather than coping.Recent studies have shown that stressfulsituations may be related to or intensifiedby a person's cognitions (Nixon & Bryant,2005). For example, if you're feelingdepressed or anxious already, you mayperceive a friend's canceling a movie dateas an indication that she doesn't want tobe with you rather than that perhaps ademand in her own life has kept her frommaking your date (Simons et al., 1993).

In reviewing certain general princi-ples of coping with stress, it is helpful toconceptualize three interactional levels:(1) on a biological level, there are immunological defensesand damage-repair mechanisms; (2) on a psychologicaland interpersonal level, there are learned coping patterns,self-defenses, and support from family and friends; and (3)on a sociocultural level, there are group resources such aslabor unions, religious organizations, and law enforcementagenCies.

The failure of coping efforts on any of these levels mayseriously increase a person's vulnerability on other levels.For example, a breakdown of immunological defenses mayimpair not only bodily functioning but psychological func-tioning as well; chronically poor psychological coping pat-terns may lead to other diseases. The impact of stress onbodily functioning and physical disorder will be discussedmore fully in Chapter 10. In coping with stress, a person isconfronted with two challenges: (1) meeting the require-ments of the stressor, and (2) protecting himself or herselffrom psychological or physical damage and disorganiza-tion. These challenges can be met in two general ways:

directed primarily at protecting the self from hurt and dis-organization, rather than at resolving the situation. Typi-cally, the person using defense-oriented responses has

forsaken more productive task-oriented action in favor of an over-riding concern for maintaining theintegrity of the self, however ill-advised and self-defeating the effortmay prove to be.

There are two common typesof defense-oriented responses. Thefirst consists of responses such ascrying, repetitive talking, andmourning that seem to function aspsychological damage-repair mech-anisms. The second type consists ofthe ego-defense or self-defensemechanisms discussed in Chapter 3.These mechanisms, including suchresponses as denial and repression,relieve tension and anxiety and pro-

tect the self from hurt and devaluation. For example, theperson who fears that her or his difficulties with intimacyand warmth may have caused a relationship to end mightcope defensively by projecting blame on the other person.Ego-defense mechanisms such as these protect a personfrom external threats such as failures in work or relation-ships, and from internal threats such as guilt-arousingdesires or actions. They appear to protect the self in one ormore of the following ways: (1) by denying, distorting, orrestricting a person's experience; (2) by reducing emo-tional or self-involvement; and/or (3) by counteractingthreat or damage.

These defense mechanisms are ordinarily used incombination rather than singly, and often they are com-bined with task-oriented behavior. Ego-defense mecha-nisms are considered maladaptive when they become thepredominant means of coping with stressors and areapplied in excess (Erickson, Feldman, Shirley, & Steiner,1996). A recent theoretical examination of coping hasattempted to refine and clarify the adaptation processthrough an interdisciplinary approach. Greve and Strobl(2004) view adaptation to stressors in terms of threemodes of adaptation: defensive, proactive, and accom-modative reactions. As noted earlier, defensive-respondingefforts attempt to reject the problem or threat. The proac-tive approach, like the task-oriented responding notedabove, involves the individual's attempting to cope withthe stress by modifying the situation. The third strategyoutlined is the accommodative effort. This approachinvolves the person's reevaluating the situation and adapt-ing to changed circumstances by modifying goals andsearching for more positive ways of responding to thecrisis. In the view of Greve and Strobl, the only success-ful coping reaction is the one that stabilizes or increaseswell-being.

In defense-oriented coping, behavior isdirected at protecting the self from hurtand disorganization, rather than solvingthe problem. So, for example, this coupleis engaged in an argument, projectingblame on each other, instead of workingtogether toward a task-oriented solution.

TASK-ORIENTED COPING A task-oriented responsemay involve making changes in one's self, one's surround-ings, or both, depending on the situation. The action maybe overt, as in showing one's spouse more affection, or itmay be covert, as in lowering one's level of aspiration. Theaction may involve retreating from the problem, attackingit directly, or trying to find a workable compromise. Eachof these actions is appropriate under certain circum-stances. For instance, if one is faced with a situation ofoverwhelming physical danger such as a forest fire, the log-ical task-oriented response might well be to run.

DEFENSE-ORIENTED COPING When a person's feelingsof adequacy are seriously threatened by a stressor, a defense-oriented response tends to prevail-that is, behavior is

IIIReVIeW~ Distinguish among stressors, stress, and

coping strategies.~ How can the nature of the stressor, the

individual's perception of it, his or her stresstolerance, and his or her external resourcesand supports modify the effects of stress?

~ What are the differences between task-oriented and defense-oriented responsesto stress?

THE EFFECTS OFSEVERE STRESSWhen stressors are sustained or severe-for example, whena child is repeatedly abused-a person may not be able toadapt and may experience lowered capability to deal withfuture events and may eventually break down under stress.This lowering of adaptive functioning is referred to aspersonality or psychological decompensation.

Our reactions to stress can give us competencies thatwe need but would not develop unless we were challengedto do so. Stress can be damaging, however, if certaindemands are too severe for our coping resources or if webelieve they are and act as though they are. Severe stresscan exact a high cost in terms of lowered efficiency, deple-tion of adaptive resources, wear and tear on the biologicalsystem, and, in extreme cases, severe personality and phys-ical deterioration-even death.

In using its resources to meet one severe stressor, anorganism may suffer a lowering of tolerance for otherstressors. Selye (1976b) demonstrated that successions ofnoxious stimuli can have lethal effects on animals. Itappears that an organism's coping resources are limited. Inattempting to understand how stress affects the organism,Selye incorporated the concept of homeostasis, or the "bal-anced" state in which an organism finds itself when basicbiological needs are being met. When the organism isstressed, it is thrown out of homeostatic balance. Anotherphenomenon involved in the effects of stress on an organ-ism is allostasis, the process of adaptation or achieving sta-bility through change. For example, in order to meet thedemands of a stressor, the organism mobilizes bodilyresources via the action of adrenaline. Under prolongedstress, these bodily systems are activated on a continuingbasis-that is, they fail to shut down when no longerneeded. The frequent mobilization of these systems understress is referred to as an allostatic load (McEwen & Stellar,1993), and it results in wear and tear on the body. If the

organism's resources are already mobilized against onestressor, they are less available to react to others. This find-ing helps explain how sustained psychological stress canlower biological resistance to disease (see Chapter 10).Interestingly, prolonged stress may lead either to patholog-ical overresponsiveness to stressors, as illustrated by the"last straw" response, or to pathological insensitivity tostressors, as shown by the loss of hope or extreme apathy insome "stressed out" people. In general, severe and sus-tained stress on any level leads to a serious reduction in anorganism's overall adaptive capacity.

Biological Effects of StressPersistent or severe stress (trauma) can markedly alter aperson's physical health, as will be further detailed inChapter 10. It is difficult to specify the exact biologicalprocesses underlying a person's response to traumatic situ-ations. Fullerton and Ursano (1997) pointed out that thereare substantial gaps in psychiatry's current understandingof responses to trauma. However, one model that helpsexplain the course of biological decompensation underexcessive stress is the general adaptation syndromeintroduced by Selye (1956, 1976b). This explanatory viewhas been supported by research in the field (Cooper &Dewe, 2004). Selye found that the body's reaction to sus-tained and excessive stress typically occurs in three majorphases: (1) an alarm reaction, in which the body's defen-sive forces are "called to arms" by activation of the auto-nomic nervous system; (2) a stage of resistance, in whichbiological adaptation is at the maximal level in terms ofbodily resources used; and (3) exhaustion, in which bodilyresources are depleted and the organism loses its ability toresist-and at this point, further exposure to stress canlead to illness and death. A diagram of Selye's general adap-tation syndrome is shown in Figure 5.1 on page 152.

STRESS AND THE SYMPATHETIC NERVOUS SYSTEMEver since the pioneering work of Cannon (1915), wehave been aware of the important role the sympatheticnervous system (SNS) plays in response to stressful ordangerous situations. When an organism is faced withdanger, the sympathetic nervous system dischargesadrenaline to prepare the organism for "flight or fight" asfollows: (1) The heart rate is increased, and blood flow(and blood pressure) are increased to the large muscles toprovide the organism with the capability of reacting tophysical threats. (2) The pupils are dilated so that morelight enters the eye. (3) The skin constricts to limit bloodloss in the event of injury. (4) Blood sugar is increased toprovide more ready energy. Through this biological reac-tion, the organism is made ready for "emergency" physi-cal effort, although most people today are seldom insituations that require the kind of activation provided byour ancestor's biological makeup. Our biochemistry andphysiology, which are similar to those of our Stone Age

Counter-Shock shock

Phase 1Alarm reaction

Phase 2

Stage of resistance

Normal level ofresistance to stress

eliminating acute fatigue. But theemphasis is on the word almost.Since we constantly go throughperiods of stress and rest duringlife, even a minute deficit ofadaptation energy every day addsup-it adds up to what we callaging. (1976a, p. 429)

Considerable research hasbeen devoted to exploring theimpact of sympathetic ner-vous system overactivation intraumatized populations(Shalev, 2000). Many studieshave examined the neuro-transmitters that are involvedwhen the SNS is activated:norepinephrine, epinephrine,and dopamine. For example,studies have compared the lev-els of these substances inpatients undergoing severestress and in control samples(Yehuda, 2002; Yehuda et al.,1992). Several studies haveshown marked elevations indifferent physiological para-meters such as heart rate and

blood pressure. Davidson and Baum (1986) studied theeffects of stress over a 5-year period following the March1979 nuclear accident at Three Mile Island. They foundthat even 5 years after the incident, people who had beenexposed to the incident showed elevated blood pressureand the presence of urinary noradrenaline (often associ-ated with a persistent arousal state). These people alsoreported more intense psychological symptoms of stresssuch as intrusive thoughts than residents in the controlcommunity did.

Another way to evaluate the effects of stress on biolog-ical systems under controlled conditions involves what isreferred to as a "challenge" study. In this approach, theresearch subject, a trauma victim perhaps, is later exposedto external stimuli resembling the original trauma-suchas an audio recording of an event that is similar to the trau-matic situation-while the researcher records the individ-ual's biological response. One study found increasedsubjective distress, blood pressure, heart rate, and epineph-rine levels in combat veterans with PTSD when they lis-tened to tapes of war sounds (McFall, Murburg, Ko, &Veith, 1990).

Research on the role of the sympathetic nervous sys-tem in stressful situations has demonstrated that the stressresponse can have a significant impact on an individual'scardiovascular system (see Figure 5.2). Severe trauma andpersistent stress can increase an individual's blood pres-sure so much that arteriosclerotic damage can occur in the

Phase 3Exhaustion

Selye's General Adaptation Syndrome (GAS)

Selye found that a typical person's general response to stress occurs in three phases. In thefirst phase (alarm reaction), the person shows an initial lowered resistance to stress or shock.If the stress persists, the person shows a defensive reaction or resistance (resistance phase) inan attempt to adapt to stress. Following extensive exposure to stress, the energy necessary foradaptation may be exhausted, resulting in the final stage of the GAS-collapse ofadaptation(exhaustion phase).

ancestors, have in several important respects failed toadapt to our present circumstances (Carruthers, 1980).Our biology is perhaps more geared to such physical chal-lenges as escaping from wild animals than to modern-dayactivities. Moreover, once the stress response has been acti-vated over long periods or in an extreme manner, itbecomes more difficult to return to homeostasis-that is,it is hard to shut off the organism's natural stress response.

In his informative book on the biological conse-quences of stress Why Zebras Don't Get Ulcers (1994),Robert Sapolsky has pointed out that "it might seem ...that chronic or repeated stressors make you sick. It is actu-ally more accurate to say that chronic or repeated stressorscan potentially make you sick or can increase your risk ofbeing sick" (p. 17).

After we have had our sympathetic nervous systemsactivated and are biologically ready for physical combat,what happens after the physical threat vanishes? Most of usprobably believe that even after a very stressful experience,rest can completely restore us. However, any employmentof the stress response inflicts a degree of wear and tear onthe system. In his pioneering studies of stress, Selye foundthis evidence:

Experiments on animals have clearly shown that eachexposure leavesan indelible scar, in that it uses upreserves of adaptability, which cannot be replaced. It istrue that immediately after some harassing experience,rest can restore us almost to the original levelof fitness by

Heart rateincreases

"Flight or Rght" ResponseThis drawing illustrates the situation when an organism is facedwith danger and the sympathetic nervous system dischargesadrenaline to prepare the organism for "flight or fight. " Severalprocesses are involved: (1) The heart rate increases, and bloodflow (and blood pressure) increase to the large muscles,providing the organism with the capability of reacting tophysical threats. (2) The pupils dilate so that more light entersthe eye. (3) The skin constricts to limit blood loss in the event ofinjury. (4) Blood sugar increases to provide more ready energy.

Anteriorcommissure

heart and blood vessels, placing the individual at risk forhypertension, heart attack, and stroke (see Chapter 10).

STRESS AND THE IMMUNE SYSTEM Stress can alsoact through the hypothalamic-pituitary-adrenal glandsto produce a serious endocrine imbalance that takes amajor toll on a person's immune system (see Figure 5.3).The hypothalamus releases hormones that stimulate thepituitary to release other hormones that regulate manybodily functions such as tissue and bone growth andreproduction. Stress, operating through the hypothala-mic-pituitary-adrenal system, can result in a suppressionof the immune system (Shigenobu, 2001; Yehuda, 2002),making people vulnerable to diseases to which theywould normally be immune (Maier, 2001). Although noone really knows why the immune system is suppressedduring periods of stress, this emergency response processprobably served a protective function in the evolution ofour species. For example, it may have prevented anorganism from acquiring autoimmune diseases by devel-oping resistance (Sapolsky, 1994). However, it is clear thatsuppression of the immune system under chronic stresscan have dire long-range health consequences. The rela-tively new field of psychoneuroimmunology focuses onthe effects of stressors on the immune system. Having alowered immune system response can mean that an indi-vidual is vulnerable to communicable diseases as well asto major mental health problems such as depression(O'Shea, 2001).

Numerous studies have shown a link between stressand the experience of extreme emotional states such asgrief (Irwin et a!', 1987), marital conflict (Loving, Heffner,

Corpuscallosum

r- Fourth~ ventricle

MedullaDescending hypothalamusconnections

This diagram shows a cross sectionof brain structures such as thehypothalamus that are involved inhuman stress responses.

et aI., 2004), separation and divorce (Kiecolt-Glaser &Glaser, 1988), recovery from surgery (Kiecolt-Glaser et aI.,1998), and examination stress (Workman & La Via, 1987).In their evaluation of research on how changes in theimmune system could affect health, Zakowski, Hall, andBaum (1992) noted the extreme importance of theimmune system in response to stress. The organs and cellsassociated with the immune system provide the body'smajor defense against foreign organisms and other poten-tial dangers. The skin prevents the intrusion of a vastonslaught of microbes and molecules in the air and wateraround us; and the rest of the immune system provides astrong defense against diseases such as cancer and humanimmunodeficiency virus (HIV) disease. They concludedthat the immune system protects us against autoimmunediseases and maintains a balance of cells that maximizesour survival.

Psychological Effects ofLong-Term StressPersonality decompensation in the face of trauma is some-what easier to specify. It appears to follow a course resem-bling that of biological decompensation and may in factinvolve specific biological responses:

1. ALARM AND MOBILIZATION. First, a person'sresources for coping with a trauma are alerted and mobi-lized. Typically involved at this stage are emotional arousal,increased tension, heightened sensitivity, greater alertness(vigilance), and determined efforts at self-control. At thesame time, in attempts to meet the emergency, the personundertakes various coping measures that may be task-oriented, defense-oriented, or a combination of the two.During this stage, symptoms of maladjustment mayappear, such as continuous anxiety and tension, gastroin-testinal upset or other bodily diseases, and lowered effi-ciency, signs that the mobilization of adaptive resources isinadequate.

2. RESISTANCE. If trauma continues, a person is oftenable to find some means of dealing with it and thus tomaintain some adjustment to life. Trauma resistance maybe achieved temporarily by concerted, task-oriented cop-ing measures; the use of ego-defense mechanisms may alsobe intensified during this period. Even in the resistancestage, however, indications of strain may exist. For exam-ple, psychophysiological symptoms such as acute stomachdistress and mild reality distortions (e.g., hypersensitivityto sounds during the late phases of this stage) may occur.In addition, the person may become rigid and cling to pre-viously developed defenses rather than try to reevaluatethe traumatic situation and work out more adaptive cop-ing patterns.

3. EXHAUSTION. In the face of continued excessivetrauma, a person's adaptive resources are depleted, andthe coping patterns called forth in the stage of resistance

begin to fail. As the stage of exhaustion begins, the indi-vidual's ability to deal with continuing stress is substan-tially lowered, and she or he may employ exaggerated andinappropriate defensive measures. The latter reactionsmay be characterized by psychological disorganizationand a break with reality involving delusions and halluci-nations. These delusions appear to represent increasinglydisorganized thoughts and perceptions, along with des-perate efforts to salvage psychological integration andself-integrity by restructuring reality. Metabolic changesthat impair normal brain functioning may also beinvolved in delusional and hallucinatory behavior. Even-tually, if the excessive stress continues, the process ofdecompensation proceeds to a stage of severe psycholog-ical disorganization involving continuous, uncontrolledviolence, apathy, stupor, and perhaps even death.

In ReVIew~ Describe the three phases of Selye's

general adaptation syndrome. Comparethem with the three stages of personalitydecompensation.

~ What is the effect of stress on thesympathetic nervous system?

~ What is the effect of stress on the immunesystem?

ADJUSTMENT DISORDER:REACTIONS TO COMMONLIFE STRESSORSA person whose response to a common stressor such asmarriage, divorce, childbirth, or losing a job is maladap-tive and occurs within 3 months of the stressor can be saidto have an adjustment disorder. The person's reaction isconsidered maladaptive if he or she is unable to functionas usual or if the person's reaction to the particular stres-sor is excessive. In adjustment disorder, the person's mal-adjustment lessens or disappears when (1) the stressorhas subsided or (2) the individual learns to adapt to thestressor. Should the symptoms continue beyond 6 months,DSM -IV-TR recommends that the diagnosis be changed tosome other mental disorder. As will be evident in the dis-cussion below, the reality of adjustment disorders does notalways adhere to such a strict time schedule.

What would be considered a normal response to astressor? The answer seems a bit elusive in DSM criteria. InDSM -IV-TR no separate category exists for stress disor-

ders; rather, acute stress disorder and post-traumatic stressdisorder are categorized under the anxiety disorders.

Clearly, not all reactions to stressors are adjustmentdisorders. What seems to push a normal reaction into thiscategory of post -traumatic stress disorder is the inability tofunction as usual, and yet this criterion applies to manyother disorders (such as anxiety disorder) as well. We willnot resolve this uncertainty any time soon; it is perhapsmore important to recognize that adjustment disorder isprobably the least stigmatizing and mildest diagnosis atherapist can assign to a client.

Adjustment Disorder Caused byUnemploymentWork-related problems can produce great stress inemployees (Williams, Barefoot, et aL, 1997). One extremelystressful situation that occurs all too frequently in today'sbusiness climate is loss of gainful employment. Managingthe stress associated with unemployment requires greatcoping strength, especially for people who have previouslyearned an adequate living. The misfortune of losing one'sjob and being unable to find suitable employment has beencommon in the United States since the Great Depression ofthe 1930s. The frequent restructuring of businesses hasresulted in the laying off of many people, transformingmany thriving communities into depressed areas andmany industrious employees into unemployed or under-employed people. In almost every community, one canfind workers who have been laid off from jobs they hadheld for many years and who are facing the end of theirunemployment compensation.

Unemployment is an especially acute problem insome population subgroups. For example, many youngminority males live in a permanent economic depressionthat is more pervasive and just as debilitating as the GreatDepression was for the white majority (Department ofLabor, 1999). Indeed, for young black men, rates of unem-ployment are over twice those for whites. The long-rangepsychological consequences of unemployment can bedevastating. Some people can deal with the setback ofsudden job loss and can adapt without long-range adjust-ment difficulties once the initial stressful situation hasended. For others, however, unemployment can have seri-ous long-term effects. The impact of chronic unemploy-ment on a person's self-concept, sense of worth, andfeeling of belongingness is shattering, especially in anaffluent society.

Adjustment Disorder Caused byBereavementThe sudden, unexpected death of a loved one accounts forabout one-third of all post-traumatic stress disorder, orPTSD, cases seen in a community (Breslau, Kessler,Chilcoat, et aL, 1998). When someone close to us dies, we

Managing the stress associated with unemployment requires greatcoping strength. Some people can deal with setbacks and can adaptwithout suffering long-range adjustment difficulties once the initialstressful situation has ended. The impact of chronic unemployment,however, con be shattering and can have serious long-term effects.

are psychologically stunned. Often the first reaction is dis-belief. Then, as we begin to realize the significance of thedeath, our feelings of sadness, grief, and despair (even,perhaps, anger at the departed person) frequently over-whelm us.

Grief over the loss of a loved one is a natural processthat allows the survivors to mourn their loss and then freethemselves for life without the departed person. Somepeople do not go through the typical process of grieving,perhaps because of their personality makeup (defensivecoping styles) or as a consequence of their particular situ-ations. A person may, for instance, be expected to be sto-ical about his or her feelings or may have to manage thefamily's affairs. Another person may develop exaggeratedor prolonged depression after the grieving process shouldhave ended. A normal grieving process typically lasts up toabout a year and may involve negative health effects suchas high blood pressure, changes in eating habits, and eventhoughts of suicide (Prigerson, Bierhals, Kasl, Reynolds,et aL, 1997).

Complicated or prolonged bereavement is oftenfound in situations where there has been an untimely orunexpected death (Kim & Jacobs, 1995). Pathological reac-tions to death are also more likely to occur in people whohave a history of emotional problems or who harbor agreat deal of resentment and hostility toward the deceasedand thus experience intense guilt. They are usually pro-foundly depressed and may, in some instances, be sufferingfrom major depression (see Chapter 7). The following caseillustrates an extreme pattern of withdrawal or pathologi-cal grief reaction (and, in this instance, a positive outcome)following a tragic death.

Some people express extreme reactions to death of a loved one.When Marine casualty officers told Carlos Arredondo of his son'sdeath in Iraq, Arredondo became distraught. He smashed thewindows of the Marine Corps van, climbed inside, and then /it thevan on fire. Arredondo was saved by the marine officers, thoughhe suffered severe burns.

Nadine, a 66-year-old former high school teacher, livedwith Charles, age 67, her husband of 40 years (also aretired teacher). The couple had been nearly inseparablefrom the time they first met-they even taught at thesame schools during most of their teaching careers. Theylived in a semirural community where they had workedand raised their three children, all of whom had marriedand moved to a large metropolitan area about 100 milesaway. For years they had planned their retirement andhad hoped to travel around the country visiting friends. Aweek before their fortieth anniversary, Charles had aheart attack and, after 5 days in the intensive care unit,had a second heart attack and died.

Nadine took Charles' death quite hard. Even thoughshe had much emotional support from her many friendsand her children, she had great difficulty adjusting. Elaine,

one of her daughters, went and stayed a few days andencouraged her to come to the city for a while. Nadinedeclined the persistent invitation even though she had lit-tle to do at home. Friends called on her frequently, but sheseemed almost to resent their presence. In the months fol-lowing the funeral, Nadine's reclusive behavior persisted.Several well-wishers told Elaine that her mother was notleaving the house even to go shopping. They reported thatNadine sat alone in the darkened house, not answeringthe phone and showing reluctance to come to the door.She had also lost interest in activities she had onceenjoyed.

Greatly worried about her mother's welfare, Elaineorganized a campaign to get her mother out of the house.Each of Nadine's children and their families took turnsvisiting and taking her places until she finally began toshow interest in living again. In time, Nadine agreed to goto each of their homes for visits. This proved a therapeu-tic step- Nadine had always been fond of children andtook pleasure in the time spent with her eight grandchil-dren -and she actually extended the visits longer thanshe had planned.

Adjustment Disorder Caused byDivorce or SeparationThe deterioration or ending of an intimate relationship isa potent stressor that is frequently cited as the reason whypeople seek psychological treatment. Divorce, thoughmore generally accepted today, is still a tragic and usuallystressful outcome to a once close and trusting relationship.We noted in Chapter 3 that marital disruption is a majorsource of vulnerability to psychopathology: People whoare recently divorced or separated are markedly overrepre-sented among people with psychological problems.

Many factors make a divorce or separation unpleasantand stressful for everyone concerned: the acknowledgmentof failure in a relationship important both personally andculturally; the necessity of explaining the failure to familyand friends; the loss of valuable friendships that oftenaccompanies the rupture; the economic uncertainties andhardships that both partners frequently experience; and,when children are involved, the problem of custody,including court battles, living and visitation arrangements,and so on.

After the divorce or separation, new problems typi-cally emerge. Adjustment to a single life, perhaps aftermany years of marriage, can be a difficult experience.Because in many cases it seems that friends as well as assetshave to be divided, new friendships need to be made. Newromantic relationships may require a great deal of personalchange. Even when the separation was relatively amicable,new strength to adapt and cope is needed. Thus it is notsurprising that divorce may motivate the task-orientedcoping response of seeking counseling.

In ReVIew~ What is an adjustment disorder according to

DSM-IV-TR?~ What "level of stressor" is required for a

diagnosis of Adjustment Disorder?

POST- TRAUMATIC STRESSDISORDER: REACTIONSTO CATASTROPHICEVENTSSevere psychological and physical symptoms can result fromsudden, unexpected environmental crises. These severesymptoms, often referred to as post-traumatic stress disor-der (PTSD), can include some or many of the following:

The traumatic event is persistently reexperienced bythe person through intrusive, recurring thoughts ornightmares.

The person avoids stimuli associated with the trauma(such as cars if the person was in a car crash).

The person may experience chronic tension or irri-tability, often accompanied by insomnia and theinability to tolerate noise.

The person may have impaired concentration andmemory.

Feelings of depression may take over, and the individ-ual may avoid social situations or environmentswhere he or she would be exposed to excitable stimuli.

Clearly, PTSD includes elements of anxiety-general-ized feelings of fear and apprehension-but because itbears such a close relationship to the experience of majorstress, we discuss it here and follow in Chapter 6 with cov-erage of the other anxiety disorders.

Prevalence of PTSD in theGeneral PopulationUntil quite recently, no estimates of the prevalence of thedisorder in the general population had been available.Many potential sources of crisis or trauma exist in contem-porary society, and post-traumatic stress disorder symp-toms are by no means rare in the general population. Onerecent study reported that nearly half of adults living in theUnited States will experience a traumatic event in theirlives, but only 10 percent of women and 5 percent of mendevelop post-traumatic stress disorder (Ozer & Weiss,2004). One example of a traumatizing event that resulted in

adaptation challenges is a recent earthquake in Turkey.B~oglu, Kili<;:,et al., 2004 reported that the rates of PTSDand depression that was comorbid with PTSD were, respec-tively, 23 and 16 percent at the epicenter of the quake and 14and 8 percent in Istanbul, about 100 kilometers distancefrom the center of the quake. More common traumaticevents such as accidents and violence can result in long-term adjustment problems for victims (Falsetti et al., 1995;Norris & Kaniasty, 1994). The formal diagnosis of PTSDwas not defined until 1980, and the known cases of the dis-order were largely limited to war veterans and disaster vic-tims (Breslau, 2001). Estimates of the prevalence of PTSDin the general population have been variable, but the disor-der appears to occur in about 1 in 12 adults at some time intheir lives (Breslau, 2001). The U.S. National Comorbiditystudy (Kessler et al., 1995) estimated the rate to be at about7.8 percent of the population (5 percent for men and 10.4percent for women). The reported rates are lower innational populations with fewer natural disasters and lowercrime. In a review of the published research on the preva-lence of PTSD, Resick (2001) recently estimated that 5 to 6percent of men and 10 to 12 percent of women in theUnited States have experienced PTSD at some time in theirlives. Breslau (2001) concluded that PTSD is about twice asprevalent in females as in males, largely because of the morecommon occurrence of assaultive violence-for example,beatings and sexual assault-against women.

PTSD, of course, can also occur along with otherdisorders (Ouimette & Brown, 2004). Brown, Stout, &Mueller (1999) found that 54 percent of their substanceabusers also had diagnosable PTSD. Kessler et al. (1995)noted that approximately 16 percent of people with PTSDhad one other disorder and that 54 percent of people withPTSD had three or more other diagnoses.

Many, if not most, people who are exposed to planecrashes, automobile accidents, explosions, fires, earth-quakes, tornadoes, sexual assaults, or other terrifyingexperiences show psychological shock reactions such asconfusion and disorganization. The symptoms may varygreatly, depending on the nature and severity of the terrify-ing experience, the degree of surprise, and the personalityof the individual. For example, 6 flight attendants who sur-vived a plane crash in which 47 passengers died were eval-uated 8 months after the crash-all 6 met criteria for PTSD.Eighteen months after the crash they showed no depres-sion but continued to experience a high level of stress(Marks, Yule, & De Silva, 1999).

Distinguishing between Acute StressDisorder and Post-Traumatic StressThe DSM -IV-TR provides two major classifications forpost-traumatic stress disorder: Acute Stress Disorder andPost- Traumatic Stress Disorder. For both of these disor-ders, the stressor is unusually severe, such as the destruc-tion of one's home, seeing another person hurt or killed, orbeing the victim of physical violence. Where the disorders

A. The person has been exposed to a traumatic event inwhich both of the following were present:

(1) the person experienced, witnessed, or was confrontedwith an event or events that involved actual orthreatened death or serious injury, or a threat to thephysical integrity of self or others

(2) the person's response involved intense fear,helplessness, or horror.

B. Either while experiencing or after experiencing thedistressing event, the individual has three (or more) of thefollowing dissociative symptoms:

(1) a subjective sense of numbing, detachment, orabsence of emotional responsiveness

(2) a reduction in awareness of his or her surroundings(e.g., "being in a daze")

(3) de-realization

(4) depersonalization

(5) dissociative amnesia (i.e., inability to recall animportant aspect of the trauma)

C. The traumatic event is persistently re-experienced in aleast one of the following ways: recurrent images,thoughts, dreams, illusions, flashback episodes, or asense of reliving the experience; or distress on exposureto reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections ofthe trauma (e.g., thoughts, feelings, conversations,activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g.,difficulty sleeping, irritability, poor concentration, hyper-vigilance, exaggerated startle response, motorrestlessness).

F. The disturbance causes clinically significant distress orimpairment in social, occupational, or other importantareas of functioning or impairs the individual's ability topursue some necessary task, such as obtaining necessaryassistance or mobilizing personal resources by tellingfamily members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and amaximum of 4 weeks and occurs within 4 weeks of thetraumatic event.

H. The disturbance is not due to the direct physiologicaleffects of a substance (e.g., a drug of abuse, amedication) or a general medical condition, is not betteraccounted for by the Brief Psychotic Disorder, and is notmerely an exacerbation of a preexisting Axis 1 or Axis 11

disorder.

differ is in timing and duration of symptoms. Acute stressdisorder occurs within 4 weeks of the traumatic event andlasts for a minimum of 2 days and a maximum of 4 weeks.If the symptoms last longer, the appropriate diagnosis ispost-traumatic stress disorder. The latter diagnosis, whichis not given unless the symptoms last for at least 1 month,can be further specified in terms of when the PTSD symp-toms begin. If the symptoms begin within 6 months of thetraumatic event, then the reaction is considered to beacute. If symptoms begin more than 6 months after thetraumatic situation, the reaction is considered to bedelayed (see the study by Gray, Bolen, & Litz, 2004, onSomalia peacekeepers). The delayed version ofPTSD is lesswell defined and more difficult to diagnose than disordersthat emerge shortly after the precipitating incident. Someauthorities have questioned whether a delayed reactionshould be diagnosed as PTSD at all; instead, some wouldcategorize such a reaction as some other anxiety-based dis-order. It is important to keep in mind that the criteria forpost-traumatic stress disorders specify that the reactionslast for at least 1 month.

A disaster syndrome appears to characterize thereactions of many victims of major catastrophes in whichgreat loss or public suffering has been identified (see TheWorld Around Us 5.1 on p. 160). This syndrome may bedescribed in terms of the reactions during the traumaticexperience, the initial reactions after it (the acute post-traumatic stress), and the long-lasting or late-arisingcomplications (the chronic or delayed post-traumaticstress).

A victim's initial responses following a disaster typi-cally involve three stages: (1) the shock stage, in which thevictim is stunned, dazed, and apathetic; (2) the suggestiblestage, in which the victim tends to be passive, suggestible,and willing to take directions from rescue workers or oth-ers; and (3) the recovery stage, in which the victim may betense and apprehensive and show generalized anxiety butgradually regains psychological equilibrium, often show-ing a need to tell repeatedly about the catastrophic event.It is in the third stage that post-traumatic stress disordermay develop. Recurrent nightmares and the typical needto tell the same story about the disaster again and againappear to be mechanisms for reducing anxiety and desen-sitizing the self to the traumatic experience. Tension,apprehensiveness, and hypersensitivity appear to be resid-ual effects of the shock reaction and to reflect the person'srealization that the world can become overwhelminglydangerous and threatening.

In some cases, the clinical picture may be complicatedby intense grief and depression. When a person feels thathis or her own personal inadequacy contributed to the lossof loved ones in a disaster, the picture may be further com-plicated by strong feelings of guilt, and the post-traumaticstress may last for months.

In some instances the guilt of the survivors seems tocenter on the belief that they deserved to survive no more,

A. The person has been exposed to a traumatic event in which: They experienced, witnessed, or were confronted with an eventor events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;and the person's response involved intense fear, helplessness, or horror.

B. The traumatic event is persistently re-experienced in one (or more) of the following:(1) recurrent and intrusive distressing recollections of the event(2) recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring(3) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the

traumatic event(4) psychological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic

eventC. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the

trauma), as indicated by three (or more) of the following:(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma(2) efforts to avoid activities, places, or people that arouse recollections of the trauma(3) inability to recall an important aspect of the trauma(4) markedly diminished interest or participation in significant activities(5) feelings of detachment or estrangement from others(6) restricted range of affect (e.g., unable to have loving feelings)(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal that were not present before the trauma), as indicated by two (or more) of thefollowing:(1) difficulty falling or staying asleep(2) irritability or outburst of anger(3) difficulty concentrating(4) exaggerated startle response

E. The duration of the disturbance is more than 1month.F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of

functioning.Specify if:Acute: if duration of symptoms is less than 3 months;Chronic: if duration of symptoms is 3 months or moreSpecify if:With delayed Onset: if onset of symptoms is at least 6 months after the stressor.

or perhaps even less, than those who died. As one flightattendant explained after the crash of a Miami-bound jetin the Florida Everglades that took many lives, "I keptthinking, I'm alive. Thank God. But I wondered why I wasspared. I felt, It's not fair" (Time, 1973, p. 53).

Extreme post-traumatic symptoms are not uncom-mon following serious accidents. Blanchard, Hickling, Bar-ton, and Taylor (1995) followed up with a group of motorvehicle accident victims who had sought medical attention

as a result of their accidents. They found that one-third ofthose who initially met PTSD diagnostic criteria had notexperienced a reduction in symptoms at a 12-month fol-low-up. In another incident, 1 month after a mass-murderspree by a gunman in Texas, psychologists interviewed 136terrorized survivors and diagnosed 20 percent of the menand 36 percent of the women as having PTSD. In a reviewand comparison of all published disaster research in whichestimates of postdisaster psychopathology were included,

5.1Tragedy can occur suddenly, unexpectedly, and

on an unimaginable scale, leaving survivors ina state of shock. On September 11, 2001, anti-American terrorists struck the World TradeCenter in New York with devastating effect. Fly-

ing two passenger jets into both towers of the World TradeCenter, a third airliner into the Pentagon Building in Wash-ington, DC, and a fourth into the ground in rural Pennsylva-nia, groups of terrorists left the world in a state of stunneddisbelief. These acts killed over 3,000 people from 80nations, including hundreds of emergency personnelattempting to rescue victims from the fire-ravaged build-ings as they collapsed, leaving tens of thousands of peopleto face the incredible aftermath of loss.

The events of September 11 produced an intenseperiod of grief, not only for the families and friends of thevictims, but for the entire nation and many people aroundthe world. Thousands of tragic stories unfolded over thedays following the attack.

Even those who did make it out of the buildings alivewere scarred by the experience. For example, Dwyer(2001) recounted the experiences of a window washer,

This Indian child shows distress as he looks over the damage done to his homeby the December 26, 2004, Asian Tsunami. Many people, including children,will suffer post-traumatic stress after extreme events such as the tsunami.

A Trauma of IncredibleProportions

Jan D., who was riding up the elevators of the World TradeCenter with several other people to the sixty-ninth floor towork. Suddenly they felt a muted thud. Next the elevatorswung from side to side like a pendulum and then felluntil someone pushed the emergency button. The eleva-tor finally came to a stop, and they found themselvestrapped between floors. Shortly afterward they heard anannouncement that there had been an explosion. Smokebegan to seep into the elevator. After a few moments,they forced open the elevator door:

They faced a wall, stenciled with the number "50."That particular elevator bank did not serve the 50thfloor, so there was no need for an opening. To escapethey would have to make one themselves. Mr. D. feltthe wall. Sheetrock. Having worked in construction inhis early days, he knew that it could be cut with asharp knife. No one had a knife. From his bucket,Mr. D. drew his squeegee. He slid its metal edgeagainst the wall, back and forth, over and over. He wasrelieved by other men. Against the smoke, theybreathed through handkerchiefs dampened in a con-

on average 17 percent of victims showed psychologicaladjustment problems in the aftermath of the disaster(Rubonis & Bickman, 1991). This is similar to the find-ings of La Greca, Silverman, Vernberg, and Prinstein(1996) that 18 percent of the children studied afterHurricane Andrew had symptoms of PTSD.

A person's traumatic reaction state may be morecomplicated in cases of severe loss. For example, anindividual who becomes paralyzed in an automobileaccident in which his wife is killed not only has to dealwith the grief over the loss of a close relationship butalso must do so during a long period of rehabilitationand a severely changed life. The psychological effectsof applying for disability compensation may alsocomplicate recovery from a disaster. Personal damagelawsuits tend to prolong post-traumatic symptomsbecause of the emotional hardships of litigation(Egendorf,1986).

The Trauma of RapeRape is the act of forcing someone to engage in sexualintercourse against his or her will-a situation thatcan inflict severe trauma on a victim. In our society,rape occurs with alarming frequency. An extensive

tainer of milk that Mr. P. (another occupant of the ele-vator) had just bought.

Sheetrock comes in panels about one inch thick,Mr. D. recalled. They cut an inch, then two inches.Mr. D.'s hand ached. As he carved into the third panel,his hand shook, he fumbled the squeegee and itdropped down the shaft.

He had one tool left: a short metal squeegee han-dle. They carried on with fists, feet, and handle, cuttingan irregular rectangle about 12 by 18 inches. Finally,they hit a layer of white tiles. A bathroom. They brokethe tiles. One by one, the men squirmed through theopening, headfirst, sideways, popping into the floornear a sink ....

By then, about 9:30, the soth floor was alreadydeserted, except for firefighters astonished to see thesix men emerge .... On the excruciating single-filedescent through the smoke, someone teased Mr. D.about bringing his bucket. "The company might notorder me another one," he replied. At the lsth floor,Mr. L.said, "We heard a thunderous, metallic roar. Ithought our lives had surely ended then." The southtower was collapsing. It was 9:S9. Mr. D. dropped hisbucket. The firefighters shouted to hurry. At 23 minutespast 10, they burst onto the street, ran for phones,sipped oxygen, and, five minutes later, fled as the northtower collapsed. Their escape had taken 9S of the 100

minutes. "It took up to one and a half minutes to cleareach floor, longer at the lower levels," said Mr. M., anengineer with the Port Authority. "If the elevator hadstopped at the 60th floor, instead of the soth, we wouldhave been five minutes too late."

"And that man with the squeegee was like ourguardian angel."

Since that day, Mr. D. has stayed home with hiswife and children. He has pieced together the faces ofthe missing with the men and women he knew in thestations of his old life: The security guard at theJapanese bank on the 93rd floor who used to let himin at 6:30; the people at Carr Futures on 92; the headof the Port Authority. Their faces keep him awake atnight.

His hands, the one that held the squeegee and theother that carried the bucket, shake with absence.(Dwyer, 2001)

Following the tragedy, thousands of family membersand survivors sought crisis intervention assistance in theirefforts to deal with the incredible losses. Many organiza-tions and individuals joined in the effort to help the sur-vivors deal with the devastating trauma by providingemotional support and counseling for victims (McCaslin,Jacobs, et al. 200S).

survey of college health behavior reported that 20 percentof female students acknowledged having been forced tohave sexual intercourse (Brener, McMahon, et aI., 1999).Although men and boys can and do experience rape, inmost cases the victim is a woman. Rape is the most fre-quent cause of PTSD in women (Cloitre, 2004). InChapter 13 we consider the pathology of rapists; our con-cern in this chapter is with a victim's response to rape. Instranger rape-a rape in which the victim does not knowthe offender-the victim is likely to experience strong fearof physical harm and death. In acquaintance rape, thereaction is apt to be slightly different (Frazier & Burnett,1994). In such a situation the victim may feel not only fearbut also betrayal by someone she had trusted. She may feelmore responsible for what happened and experiencegreater guilt. She may also be more hesitant to seek help orreport the rape to the police out of fear that she will beheld partially responsible for it.

The age and life circumstances of a victim may alsoinfluence her reaction (Ullman & Filipas, 2001). For ayoung child who knows nothing about sexual behavior,rape can lead to sexual scars and confusion, particularly ifthe child is encouraged to forget about the experiencewithout thoroughly talking it over first (Browne & Finkel-hor, 1986). For young adult women, rape can increase the

conflicts over independence and separation that are nor-mal in this age group. In an effort to be helpful, parents ofthese victims may encourage various forms of regression,such as moving back to the family home, which may inter-fere with mastery of this developmental phase. Marriedrape victims with children face the task of explaining theirexperience to their children. Sometimes the sense of vul-nerability that results from rape leaves a woman feelingtemporarily unable to care for her children.

Husbands and boyfriends, if unsympathetic to what awoman is undergoing after being raped, can negativelyinfluence a rape victim's adjustment. Rejection, blaming,uncontrolled anger at the offender, or insistence on a quickresumption of sexual activity can serve to increase a vic-tim's negative feelings.

McCann, Sakheim, and Abrahamson (1988) foundthat the experience of rape affected women in five areas offunctioning. First, physical disturbances, including hyper-arousal or anxiousness (typical symptoms of PTSD), werecommon. One recent study found that women who had ahistory of sexual assault tended to see themselves as inpoorer health (Golding, Cooper, & George, 1997). Second,women who had been sexually assaulted tended to experi-ence emotional problems such as anxiety, depressed mood,and low self-esteem. Fierman and colleagues (1993) found

that prior trauma, particularly sexual abuse, physicalabuse, and rape, were prominent in the life histories ofpatients seeking treatment at an anxiety clinic. Falsetti andcolleagues (1995) reported that 94 percent of their sampleof women with panic disorders had histories of criminalvictimization. Third, following rape, women tended toreport cognitive dysfunction, including disturbed concen-tration and the experience of intrusive thoughts (Valen-tiner, Foa, Riggs, & Gershuny, 1996), and some reportednegative beliefs about other people and concerns for theirown safety even a year later (Frazier, Conlon, & Glaser,2001). Fourth, many women reported engaging in atypicalbehavioral acts such as aggressive, antisocial actions andsubstance abuse after being raped. Finally, many womenwho experience rape tend to report having interference intheir social relationships, including sexual problems, inti-macy problems, and further victimization. All these symp-toms reflect those of PTSD. See Figure 5.4 for a summaryof the psychological processes rape victims go through asthey cope with their experiences.

LONG-TERM EFFECTS Whether a rape victim will expe-rience serious psychological problems depends to a largeextent on her past coping skills, resiliency in dealing withproblems, and level of psychological functioning. Aresilient and previously well-adjusted woman usually willregain her prior equilibrium, but rape can precipitatesevere pathology in a woman with psychological difficul-ties (Meyer & Taylor, 1986). Victims' perceptions ofwhether they can control future circumstances influencethe recovery process. Women who tended to blame them-selves or thought more about why the rape occurred wereslower to recover from the trauma than those who believedthat future assaults were less likely (Frazier & Schauben,1994). When problems do continue, or when they becomemanifest later in a delayed post-traumatic stress disorder,they are likely to involve anxiety, depression, withdrawal,and difficulties in heterosexual relationships (Gold, 1986;Koss,1983).

COUNSELING RAPE VICTIMS Although many sur-vivors of sexual assault postpone seeking help with theiremotional recovery (Symes, 2000), some research has sug-gested that women who participate in disclosure about therape tend to have more positive and fewer negative out-comes (Wasco, Campbell, et aI., 2004). The women's move-ment has played a crucial role in establishing specializedrape counseling services such as hotlines and rape crisiscenters staffed by trained paraprofessionals who providegeneral support for victims, both individually and ingroups. In some situations, specific trauma interventionprograms have proved effective in treating rape victims(Petrak & Hedge, 2002). Many crisis centers also have vic-tim advocacy services in which a trained volunteer accom-

panies a woman to a hospital or police station, helps herunderstand the procedures, and assists her with the redtape. The advocate may also accompany the person tomeetings with legal representatives and to the trial-expe-riences that tend to temporarily reactivate the trauma ofthe rape.

The Trauma of Military CombatMany people who have been involved in the turmoil of warexperience devastating psychological problems for monthsor even years afterward (Garakani, Hirschowitz, & Katz,2004). During World War I, traumatic reactions to combatconditions were called "shell shock," a term coined by aBritish pathologist, Co1. Frederick Mott (1919), whoregarded these reactions as organic conditions producedby minute brain hemorrhages. It was gradually realized,however, that only a small percentage of such cases repre-sented physical injury. Most victims were suffering insteadfrom the general combat situation, with its physicalfatigue, ever-present threat of death or mutilation, andsevere psychological shocks. During World War II, trau-matic reactions to combat were known as operationalfatigue and war neuroses, before finally being termedcombat fatigue or combat exhaustion in the Korean andVietnam Wars. Even the latter terms were none too aptlychosen, because they implied that physical exhaustionplayed a more important role than was usually the case.They did, however, serve to distinguish such disordersfrom other psychological disorders, such as drug use, thathappened to occur under war conditions but might wellhave occurred in civilian life.

It has been estimated that in World War II, 10 percentof Americans in combat developed combat exhaustion.However, the actual incidence is not known, becausemany soldiers received supportive therapy at their battal-ion aid stations and were returned to combat within a fewhours. In fact, combat exhaustion caused the single great-est loss of personnel during that war (Bloch, 1969). Dur-ing the Korean War the incidence of combat exhaustiondropped from an initial high of over 6 percent to 3.7 per-cent; 27 percent of medical discharges were for psychiatricreasons (Bell, 1958). In the Vietnam War the figuredropped to less than 1.5 percent for combat exhaustion,with a negligible number of discharges for psychiatric dis-orders (Allerton, 1979; Bourne, 1970). The prevalence ofPTSD symptoms among Gulf War veterans was reportedto be 12.1 percent compared with non-Gulf War veterans(4.3 percent) (Kang, Natelson, et aI., 2003). A recent sur-vey of military personnel serving in Afghanistan and Iraqreported significant percentages of soldiers who met thecriteria for depression, PTSD, and generalized anxiety dis-order. Hoge, Castro, et a1. (2004) found that between 15.6percent and 17.1 percent of participants reported thesesymptoms after duty in Iraq compared with 11.2 percent

Anticipatory PhaseThis period occurs before an actual rape, when an offender "sets up" a victim and the victimbegins to perceive that a dangerous situation exists. In the early minutes of this phase, thevictim often uses defense mechanisms such as denial to preserve an illusion of invulnerability.Common thoughts are, "This isn't really happening to me" or "He doesn't really mean that."

LImpact Phase

This phase begins with a victim's recognition that she is actually going to be raped and endswhen the rape is over. The victim's first reaction is usually intense fear for her life, a fear muchstronger than her fear of the sexual act itself. Symonds (1976) has described the paralyticeffect of intense fear on victims of crime, showing that this fear usually leads to varyingdegrees of disintegration in the victim's functioning and possibly to a complete inability toact. Barlow (Anxiety, 2002) indicated that there is evidence that people experiencing intenseanxiety go into a state of immobility. Roth and Lebowitz (1988) found that the sexual traumaconfronts the individual with emotions and images that are difficult to manage and may havelong-term adjustment consequences. When the victim later recalls her behavior during theassault, she may feel guilty about not reacting more efficiently, and she needs to be reassuredthat her actions were normal.

Post-Traumatic Recoil PhaseFollowing rape, many women experience symptoms of hyperarousal and numbing along withcontinuing intrusive symptoms and avoidance behavior (Feuer, Nishith, & Resick, 2005). Thisphase begins immediately after a rape. Burgess and Holmstrom (1974,1976) observed twoemotional styles among the rape victims they interviewed in hospital emergency rooms: (1)an expressed style, in which feelings of fear and anxiety were shown through crying, sobbing,and restlessness, and (2) a controlled style, in which feelings appeared to be masked by acalm, controlled, subdued facade. Regardless of style, most victims felt guilty about the waythey had reacted to the offender and wished that they had reacted faster or fought harder.(Excessive self-blame has been associated with poor long-term adjustment; see Meyer &Taylor, 1986.) Feelings of dependency were increased, and victims often had to beencouraged and helped to call friends or parents and to make other arrangements.

Reconstitution PhaseThis phase begins as a victim starts to make plans for leaving the emergency room or crisiscenter. It ends, often many months later, when the stress of the rape has been assimilated,the experience shared with significant others, and the victim'S self-concept restored. Certainbehaviors and symptoms are typical during this phase:1. Self-protective activities, such as changing one's telephone number and moving to a newresidence, are common. The victim's fear is often well justified at this point, because even inthe unlikely event that the offender has been arrested and charged with rape, he is often outon bail.2. Frightening nightmares in which the rape is relived are common. As the victim moves closerto assimilating the experience, the content of the dreams may gradually shift until the victimsuccessfully fights off the assailant.3. Phobias often develop immediately following rape, including fear of the indoors oroutdoors (depending on where the rape took place), fear of being alone, fear of crowds, fearof being followed, and sexual fears.

FIGURE 5.4Coping with Rape

Research with rape victimssoon after the trauma hasprovided clear insights intothe emotional turmoil andpsychological processesthey go through in copingwith their experiences(Frazier& Burnett, 1994;Koss & Figueredo, 2004).Coping actually beginsbefore the rape occurs andends many months after theattack. The categoriesoutlined in this figuresummarize these findingsand integrate the feelingsand problems that womenexperience at differentpoints of their traumas.

(3) participated in abusive violence in combat(Laufer, Brett, & Gallops, 1985). They foundthat post-traumatic symptoms includingintrusive imagery, hyperarousal, numbing,and cognitive disruption were associatedwith exposure to combat violence. Participa-tion in abusive violence was most highlyassociated with more severe pathologiesmarked by cognitive disruptions such asdepression. The authors concluded that theclinical picture of poS't-traumatic stress dis-order varies according to the stressors experi-enced. Combat involvement is also not theonly stressor in a war zone. Soldiers involvedin graves registration duties (i.e., handlingcorpses) had high rates of PTSD symptomssuch as anger, anxiety, and somatic com-plaints compared with soldiers not assignedto such duties (McCarroll, Ursano, & Fuller-ton, 1995). Moreover, some people enteringthe military are more vulnerable to develop-ing stress-related symptoms than others.

Despite these variations, the generalclinical picture was surprisingly uniform forsoldiers who developed combat stress in dif-ferent wars. The first symptoms were increas-

ing irritability and sensitivity, sleep disturbances, and oftenrecurrent nightmares. One empirical study of the emo-tional components of PTSD in combat veterans foundanger and anger control problems to be strong compo-nents in post-traumatic stress among combat veterans(Chemtob et al., 1994).

Interestingly, most physically wounded soldiers haveshown less anxiety or less combat exhaustion symptomsthan soldiers not physically wounded, except in cases ofpermanent mutilation. Apparently a wound, in providingan acceptable escape from a stressful combat situation,removes the source of anxiety. A similar finding wasreported among Israeli soldiers hospitalized during the5-to 6-week Yom Kippur War in 1973 when Egyptian andSyrian forces attacked Israel (Merbaum & He fez, 1976). Infact, it is not unusual for soldiers to admit that they haveprayed to be hit or to have something honorable happen tothem to remove them from battle. When approaching fullrecovery and the necessity of returning to combat, injuredsoldiers sometimes show prolonged symptoms or delayedtraumatic reactions of nervousness, insomnia, and othersymptoms that they did not exhibit when they were firsthospitalized.

It has been estimated that in World War II, 10 percent of Americans in combatdeveloped combat exhaustion. The stress of combat clearly took its toll on thisMarine, who had just finished 2 days of heavy fighting in the Pacific.

in Afghanistan or 9.3 percent compared to reportedsymptoms before going to Iraq. The rates of disorderincreased with the reported extent of combat and withbeing wounded in combat.

CLINICAL PICTURE IN COMBAT-RELATED STRESSThe specific symptoms of combat-related stress vary con-siderably, depending on the type of duty, the severity andnature of the traumatic experience, and the personality ofthe individual. Just being in a war zone, with the ever-pre-sent possibility that a shell can explode and kill or injureanyone in the area, is a frightening experience (Zeidner,1993). In fact, civilians living in war zones are also at riskfor PTSD. Studies of 492 Israeli elementary school childrenwho were exposed to SCUD missile attacks during the firstwar with Iraq found that higher stress responses occurredin areas that were hit by missiles (Schwarzwald et al., 1993).In another study, the anxiety levels of the civilians exposedto the threat of attack were significantly higher during thewar than when they were retested after the war was over(Weizman et aI., 1994). Moreover, anxiety was higherduring the evenings (when the SCUD attacks usuallyoccurred) than during the day.

Many studies have documented the importance ofwar-zone stressors and the development of PTSD symp-toms (Dohrenwend, Neria, et aI., 2004; Ford, 1999; Priger-son, Maciejewski, & Rosenheck, 2002). One study evaluatedthe self-reports of 251 Vietnam veterans, grouping themaccording to three levels of experienced stress: (1) exposedto combat; (2) exposed to abusive violence in combat; and

PRISONERS OF WAR AND HOLOCAUST SURVIVORSAmong the most stressful and persistently troublingwartime experiences is that of being a prisoner of war(Beal, 1995; Page, Engdahl, & Eberly, 1997). Althoughsome people have been able to adjust to the stress (espe-cially as part of a supportive group), the toll on most pris-

5. Unpredictable andUncontrollable Stressors

~

or the past 30 years, extensive research inanimals has shown that two of the mostimportant determinants of how an organismresponds to stress are whether the stressorsare unpredictable and whether they are

uncontrollable. An unpredictable stressor occurs withoutwarning, and its nature may be unforeseen. With an uncon-trollable stressor, there is no way to reduce its impact, suchas by escape or avoidance. In general, both people and ani·mals are more stressed by unpredictable and uncontrol-lable stressors than by stressors that are of equal physicalmagnitude but are either predictable or controllable orboth (e.g., Evans & Stecker, 2004; Maier & Watkins, 1998).

There are many parallels between the symptoms ofPTSDand the behavioral and physiological consequencesof unpredictable and uncontrollable stressors in animals(e.g., Ba;;oglu & Mineka, 1992; Foa, Zinbarg, & Rothbaum,1992; Friedman & Yehuda, 1995). It is known, for example,that uncontrollable stressors stimulate some brain sys-tems and increase the levels of central and peripheral nor-epinephrine (Friedman & Yehuda, 1995; Southwick,Yehuda, & Morgan, 1995). This led PTSDresearchers tohypothesize that administering a drug called yohimbine topersons with PTSDmight increase their symptoms,because yohimbine (a naturally occurring substance) isknown to activate noradrenergic neurons. In a result con-sistent with this hypothesis, Southwick and colleagues(1995) found that 40 percent of a group of 20 Vietnam vet-erans with PTSDgiven yohimbine experienced flashbacks.In addition, the veterans with PTSDshowed increases inother symptoms, such as intrusive traumatic thoughts,emotional numbing, and grief.

Uncontrollable stressors in animals are also known tocause stress-induced analgesia (SIA),or diminished sensi-tivity to pain. Formerly neutral conditioned stimuli that arepaired with uncontrollable stressors can also come to elicit

oners is great. About 40 percent of the American prisonersin Japanese POW camps during World War II died duringtheir imprisonment; an even higher proportion of prison-ers of Nazi concentration camps died. Many survivors ofNazi concentration camps sustained residual organic andpsychological damage, along with a lowered tolerance tostress of any kind. Symptoms were often extensive andcommonly included anxiety, insomnia, headaches, irri-tability, depression, nightmares, impaired sexual potency,and functional diarrhea (which may accompany even rela-tively mild stress). Such symptoms were attributed not onlyto the psychological stressors but also to biological stressors

this analgesia. SIAis known to work through the produc-tion of endogenous, or internally produced, opiate-likesubstances in the brain (Southwick et al., 1995; van derKolk& Saporta, 1993). PTSDresearchers now believe thatmany of the symptoms of emotional numbing seen in peo-ple with PTSDmay be caused by this same kind of SIA,rather than a psychological defensive reaction againstremembering the trauma.

Ifunpredictable and uncontrollable stressors are mostlikely to produce PTSD,what factors determine which ofthe people who experience those stressors will be mostlikely to develop PTSD?Again, researchers have turned tothe animal literature for answers (e.g., Mineka & Zinbarg,1995). Forexample, it is known that prior experience withuncontrollable stressors can sensitize the organism-thatis, make it more susceptible to the negative consequencesof later experiences with uncontrollable trauma. Severalstudies of PTSDhave confirmed that this is indeed thecase; for example, victims of childhood abuse are moresusceptible than others to PTSDif they experience sexualor nonsexual assault in adulthood (see Foa, Zinbarg, &Rothbaum, 1992; Mineka & Zinbarg, 1995). In addition, sol-diers who had been physically abused in childhood weremore likely than others to develop PTSDduring the Viet-nam War (Post, Weiss, & Smith, 1995). There is some evi-dence that individual characteristics such as neuroticismmight be more important than the uncontrollability ofstressors in understanding subjective arousal to aversivestimuli (Vogeltanz & Hecker, 1999).

Considerable research now supports the hypothesesthat perceptions of uncontrollability and unpredictabilityplay an important role in the development and mainte-nance of PTSDsymptoms (Anisman & Merali, 1999),although the associations between these perceptions andthe symptoms that emerge are often complex (Zakowski,Hall, et a\., 2001).

such as head injuries, prolonged malnutrition, and seriousinfectious diseases (Sigal et al., 1973; Warnes, 1973).

Among returning POWs, the effects of the psycho-logical trauma they had suffered were often masked bythe feelings of relief and jubilation that accompaniedrelease from confinement. Even when there was little evi-dence of residual physical pathology, however, survivors ofprisoner-of-war camps commonly showed impairedresistance to physical illness, low frustration tolerance,frequent dependence on alcohol and drugs, irritability,and other indications of emotional instability (Chambers,1952; Goldsmith & Cretekos, 1969; Hunter, 1978; Strange

& Brown, 1970; Wilbur, 1973). Many veterans experience,at times, overwhelming anger over minor events that forsome is difficult to control. Such maladaptive behaviorsmay require intervention even years after the stress of mil-itary combat has faded (Chemtob, Novaco, Hamada, &Gross, 1997). There is also evidence that combat exposurecan result in severe adjustment problems including antiso-cial behavior (Barrett, Resnick, Foy, & Dansky, 1996).

In a retrospective study of psychological maladjust-ment symptoms following repatriation, Engdahl and col-leagues (1993) interviewed a large sample of former POW sand found that half of them reported symptoms that metstandard criteria for PTSD in the year following theirreleases from captivity; nearly a third met PTSD criteria 40to 50 years after their wartime experiences.

Another measure of the toll taken by the prolongedstress of being in a POW or concentration camp is thehigher death rate after return to civilian life. Amongreturning World War II POWs from the Pacific area, Wolff(1960) found that within the first six years, nine times asmany died from tuberculosis as would have been expectedin civilian life; four times as many from gastrointestinaldisorders; over twice as many from cancer, heart disease,and suicide; and three times as many from accidents. Manyproblems of adjustment and post-traumatic symptomscan be found in POWs years after their release (Sutker &Allain, 1995). Bullman and Kang (1997) found an increasedrisk of death due to external causes (for example, fromoverdose and accidents) associated with PTSD in Vietnamveterans.

Some of the lingering problems experienced by for-mer POW s might be a direct result of harsh treatment andstarvation during captivity. Sutker and colleagues (1992)conducted a study of memory and cognitive performanceof POW survivors and found that those who experiencedthe greatest trauma-induced weight loss, defined as greaterthan 35 percent of their weight before captivity, performedsignificantly worse on memory tasks than POWs whoexperienced less malnutrition.

Severe Threats to Personal Safetyand SecuritySome of the most traumatic and psychologically disablingcircumstances a person can experience involve those inwhich he or she faces drastic threats to personal security.Even living in a modern, civilized world is no guarantee ofuninterrupted peaceful pursuit of our dreams and ambi-tions. All too often in the modern world, we hear abouttragic sociopolitical circumstances that require large pop-ulations to leave their homeland and join a scattered trailof refugees to some unknown place where they are subjectto lawless and inhumane treatment (Miller & Rasco, 2004).

THE TRAUMA OF FORCED MIGRATION In 1999 morethan 14.1 million refugees and asylum seekers fled their

countries, and another 21 million were displaced withintheir own countries (U.S. Committee for Refugees, 2001).

In the United States, recent refugees have come frommany countries-Ethiopia, the former Soviet Union, Iran,Cuba, Haiti, Laos, Vietnam, Cambodia, and Somalia. TheSoutheast Asians who began arriving in America after1975 perhaps had the most difficult adjustment. Althoughmany of these people were functioning well in theirhomeland and in time became successful and happyAmerican citizens, others have had difficulty adjusting(Carlson & Rosser-Hogan, 1993; Westermeyer, Williams,& Nguyen, 1991). Not surprisingly, refugees with low self-esteem tend to have the most difficulty adjusting to newcultures (Nesdale, Rooney, & Smith, 1997). A 10-year lon-gitudinal study of Hmong refugees from Laos found thatmany refugees had made considerable progress in theiracculturation (Westermeyer, Neider, & Callies, 1989).Many had improved economically-about 55 percentwere employed, with incomes approaching those of thegeneral population. The percentage of people living onwelfare had dropped from 53 percent initially to 29 per-cent after 10 years. Psychological adjustment had alsoimproved, with symptoms of phobia, somatization, andlow self-esteem showing the most positive changes. Con-siderable problems remained, however. Many refugeesstill had not learned English, some seemingly had settledpermanently onto the welfare rolls, and some still showedsymptoms such as anxiety, hostility, and paranoia that hadchanged little over the period studied. Although manyrefugees had adapted to their new culture, many were stillexperiencing considerable adjustment problems even after10 years in the United States (Hinton, Tiet, et aI., 1997;Westermeyer, 1989) or in other refugee countries such asNorway (Hauff &Vaglum, 1994).

Many adults who emigrate-especially those forcedto leave their homes-experience a high degree of stressand problems in psychological adjustment. However,even greater degrees of stress can occur in their children(Rousseau, Drapeau, & Corin, 1996). In a study of Chinesemigrants to Canada, Short and Johnston (1997) found thatthe degree of stress in children was often buffered bygreater adjustment in the parents. Their study highlightedthe importance of measuring stress levels of adults andimplementing strategies to alleviate their settlement con-cerns in order to lower the level of stress for children. Inmany cases, however, young refugees do not live with theirparents but with distant relatives or friends, a situation thatcan result in added adaptation stress (Hak6n, Robertson,et al., 2004).

THE TRAUMA OF BEING HELD HOSTAGE Being held asa hostage can produce disabling psychological symptomsin victims (Allodi, 1994). The following case (adaptedfrom Sonnenberg, 1988) describes a man who experienceda horrifying ordeal that left him with intense symptoms ofanxiety and distress for months following the incident.

Mr. A. was a married accountant, the father of two, in hisearly thirties. One night, while out performing an errand,he was attacked by a group of youths. These youngstersmade him get into their car and took him to a desertedcountry road.

There they pulled him from the car and began beat-ing and kicking him. They took his wallet, began tauntinghim about its contents (they had learned his name, hisoccupation, and the names of his wife and children), andthreatened to go to his home and harm these familymembers. Finally, after brutalizing him for several hours,they tied him to a tree, one youth held a gun to his head,and after Mr. A. begged and pleaded for his life, thearmed assailant pulled the trigger. The gun was empty,but at the moment the trigger was pulled, the victim defe-cated and urinated in his pants. Then the youths untiedhim and left him on the road.

This man slowly made his way to a gas station hehad seen during his abduction and called the police. [Oneof the authors] was called to examine him and did so atintervals for the next 2 years. The diagnosis was PTSD.Hehad clearly experienced an event outside the range ofnormal human experience and was at first reexperiencingthe event in various ways: intrusive recollections, night-mares, flashbacks, and extreme fear upon seeing groupsof unsavory-looking youths. He was initially remarkablynumb in other respects: He withdrew from the membersof his family and lost interest in his job. He felt generallyestranged and detached. He expected to die in the nearfuture. There were also symptoms of increased psy-chophysiological arousal: poor sleeping, difficulty con-centrating, and exaggerated startle response. When [theauthors] first spoke about his abduction in detail, heactually soiled himself at the moment he described doingso during the original traumatic experience.

This man received treatment from another psychia-trist during the next 2 years, consisting of twice-weeklyintensive individual psychotherapy sessions and the con-current administration of a tricyclic antidepressant. Theindividual psychotherapy consisted of discussions thatfocused on the sense of shame and guilt this man feltover his behavior during his abduction. Hewished he hadbeen more stoic and had not pleaded for his life. With thehelp of his psychotherapist, he came to see that he couldaccept responsibility for his behavior during his captivity;that his murderous rage at his abductors was under-standable, as was his desire for revenge; and that hisresponse to his experience was not remarkable com-pared with what others might have felt and done.

Eventually he began to discuss his experience withhis wife and friends, and by the end of the 2 years overwhich [the author] followed him, he was essentially

without symptoms, although he still became somewhatanxious when he saw groups of tough-looking youths.Most important, his relationship with his wife and chil-dren was warm and close, and he was again interestedin his work.

PSYCHOLOGICAL TRAUMA AMONG VICTIMS OF TOR-TURE Among the most highly stressful experienceshuman beings have reported are those inhuman acts per-petrated upon them by other human beings in the form ofsystematic torture. From the beginning of human historyto the present, some people have subjected others to pain,humiliation, and degradation for political or inexplicablepersonal reasons (Jaranson & Popkin, 1998). History andliterature are full of personal accounts of intense sufferingand lifelong dread resulting from maltreatment by ruth-less captors. In addition, several empirical studies havereported on the prevalence of torture in the modern world:Allden and colleagues (1996) reported that 38 percent ofBurmese political dissidents who escaped to Thailand hadbeen tortured before their escape. Shrestha, Sharma, andcolleagues (1998) compared Bhutanese survivors of tor-ture in a Nepalese refugee camp with matched controls andfound that torture survivors had more PTSD, anxiety, anddepressive symptoms than the controls. Van Ommeren, deJong, et a1. (2001) compared tortured and nontorturedBhutanese refugees and reported that those acknowledg-ing being tortured had had more PTSD, somatoform pain,and dissociative disorders over the past year, as well as hav-ing had more lifetime mood affective and generalized anx-iety disorders. Silove, Steel, et a1. (2002) also found higherPTSD scores in a sample of Tamil torture victims living inAustralia when compared with refugees who had not beentortured.

These studies are somewhat limited in terms of theirgeneralizability in that they typically have used small ornonrepresentative samples of torture survivors. One recentstudy conducted with a substantial and representative sam-ple of African refugees from Somalia and Ethiopia living inthe United States provided a reliable estimate of the preva-lence rates for torture for a large sample of 1,134 refugees.The sample contained approximately 600 refugees of eachnationality, with equal numbers of men and women. Of theparticipants in the study, only about 56 percent met thecriteria for no torture, while the remainder reported a his-tory of having been tortured. These rates of torture weresubstantially higher than other studies have reported. Theexperience of torture varied by gender and ethnicity: 45percent men (n = 272) and 43 percent women (n = 228)had approximately equal exposure to torture. More of theEthiopians were exposed to torture (n = 286,55 percent)than Somalis (n = 224, 36 percent) (Jaranson, Butcher,et aI., 2004).

Psychological symptoms experienced after torturehave been well documented and involve a range of prob-lems including physical symptoms (such as pain, nervous-ness, insomnia, tremors, weakness, fainting, sweating, anddiarrhea); psychological symptoms (such as night terrorsand nightmares, depression, suspiciousness, social with-drawal and alienation, irritability, and aggressiveness);cognitive impairments (such as trouble concentrating, dis-orientation, confusion, and memory deficits); and unac-ceptable behaviors (such as aggressiveness, impulsivity,and suicidal attempts; see Ba!loglu & Mineka, 1992; Bur-nett & Peel, 2001).

The following case is illustrative of the post-tortureexperience:

Muhammad B.,a 21-year-old Ethiopian refugee,lives withhis mother, father, two younger brothers, and twoyounger sisters in a small center-city apartment buildingin a large Midwestern city. He works part time as a park-ing lot attendant and attends night school, majoring inbusiness. Muhammed has been in the United States for 5years after a very tumultuous period in his home country.He was held for interrogation, along with several otheryouths from his village, in a government prison com-pound for several months when he was 15 years old. Thetreatment received by the captives was severe, includingstarvation and frequent physical punishment. During a 7-month period of confinement, he was interrogated, usu-ally after a severe beating or after being shown thebodies of other prisoners, in an effort by his captors toobtain information about the whereabouts of antigovern-ment guerilla fighters. On one occasion he was ques-tioned while one of the guards held a rifle barrel in hismouth, and on another occasion he was subjected to a"staged execution" in order to get him to talk. After thecaptors determined that he had no relevant information,he was released. Hisfamily was able to escape the coun-try shortly afterward.

Since his release from imprisonment, Muhammedhas experienced severe PTSDsymptoms including nightterrors, sleeping disturbances, attacks of intense anxiety,and depression. He reports almost constant headachesand pains in the hand that was broken by his captors.

Although Muhammad has been able to completehigh school successfully in the United States and hasaccumulated a year of college credit going to school parttime, his day-to-day functioning is characterized by dis-abling, intrusive thoughts, anxiety, nightmares, and recur-ring depression.

Most of what we know about the psychological con-sequences of torture comes from anecdotal reports byvictims. The experiences of torture victims have also beenempirically evaluated in well-controlled studies of vic-tims. In the study of Somali and Ethiopian torture victimsnoted above (Jaranson, Butcher, et al., 2004), torture sur-vivors reported substantially higher numbers of physicaland psychological problems and also scored higher on aPTSD checklist (the PCL-C) than refugees who had notbeen tortured.

In another study, Ba!loglu and his colleagues (1994)studied the long-term consequences of torture, and possi-ble rehabilitation strategies. They reported the results of aunique empirical study in which 55 former Turkish pris-oners who were political activists were compared with 55political activists who were not tortured. The torture vic-tims and control subjects were located through articles andads in newspapers and political journals. The investigatorswere able to match the victims and controls closely on anumber of variables including age, gender, education level,ethnic status, and occupation. To obtain an objectivepicture of each person's adjustment and psychologicalsymptoms, they used a number of standard assessmenttechniques: a psychiatric interview and a number of stan-dardized psychological tests including the Turkish lan-guage MMPI, the Beck Depression Scale, and theState-Trait Anxiety Inventory.

Although the victims of torture were for the most partnot found to be extremely psychiatrically disturbed com-pared with the controls, the victims of imprisonment andtorture were found to experience significant symptoms ofpost-traumatic stress disorder related to being uprooted,being a refugee, living in a repressive political environ-ment, and living through related traumatic events. More-over, Ba!loglu and his colleagues found evidence thattorture induces psychological effects independent of otherstressors (1994). Interestingly, the authors found that trau-matic experience from torture had a differential impactdepending on the manner in which the torture wasapplied-that is, whether the torture was perceived by thevictim as uncontrollable and unpredictable (Ba!loglu &Mineka, 1992). Victims who were able to assert someelement of cognitive control over the circumstances (forexample, those who were able to predict and ready them-selves for the pain they were about to experience) tendedto be less affected over the long term (see Developmentsin Research 5.2). These investigators concluded that priorknowledge of and preparedness for torture, strong com-mitment to a cause, immunization against traumaticstress as a result of repeated exposure, and strong socialsupports have protective value against PTSD in survivorsof torture.

In a further follow-up study of torture victims,Ba!loglu, Mineka, and colleagues (1997) found additionalsupport for the idea that psychological preparedness for

trauma is an extremely important protective factor forlessening the psychological effects of torture.

Causal Factors inPost- Traumatic StressMost people function relatively well in catastrophes, andmany behave with heroism (Rachman, 1990). Whether ornot someone develops post-traumatic stress disorderdepends on a number of factors. Some research suggeststhat personality plays a role in reducing vulnerability tostress when the stressors are severe (Clark, Watson, &Mineka, 1994). At high levels of traumatic exposure, thenature of the traumatic stressor can account for much ofthe differences in stress response (e.g., Lifton, 2005). Inother words, everyone has a breaking point, and at suffi-ciently high levels of stress, the average person can beexpected to develop some psychological difficulties (whichmay be either short-lived or long term) following a trau-matic event. Epstein, Fullerton, and Ursano (1998) foundthat workers who provide support to bereaved families ofdisaster victims are themselves at risk for increased illness,psychiatric symptoms, and negative psychological well-being for up to 18 months following the disaster. They alsoreported that individuals with lower levels of education,those who had exposure to grotesque burns, and thosewho had strong feelings of numbness following exposurewere more likely to experience later psychological symp-toms after an air disaster.

Even a seasoned police officer can experience a dis-abling level of stress, as shown in the following case.

The Police Officer andthe Plane Crash

Don had been a model police officer during his 14 yearson the force. He was evaluated highly by his superiors,had an M.A.in social work, and had attained the rank ofsergeant. While patrolling in a squad car, he heard thatthere had been an aircraft accident, and he quickly droveto the scene to give aid to any survivors. After he arrived,he wandered around in a daze looking for someone tohelp, but there was only destruction. He later remem-bered the next few days as a bad dream.

For several days after the cleanup he was quitedepressed, had no appetite, couldn't sleep, and wasimpotent. Images and recollections of the accident wouldcome to him out of nowhere. He reported having a recur-ring dream inwhich he came upon an airplane crash whiledriving a car or flyinga plane. Inhis dream, he would rushto the wreckage and help some passengers to safety.

Don decided that he needed help and sought coun-seling. Because of his deteriorating mood and physicalcondition, he was placed on medical leave from the policeforce. Eight months after the accident he was still intherapy and had not returned to work. During therapy itbecame apparent that Don had been experiencing agreat deal of personal dissatisfaction and anger prior tothe crash. His prolonged psychological disorder was notonly a result of his anguish over the air crash but also avehicle for expressing other problems. (Based on David-son, 1979a, 1979b; O'Brien, 1979.) See Davisand Stewart(1999) for a discussion of the aftermath of this accident20 years later.

In all cases of post-traumatic stress, conditionedfear-the fear associated with the traumatic experience-appears to be a key causal factor. Thus prompt psychother-apy following a traumatic experience is consideredimportant in preventing conditioned fear from establish-ing itself and becoming resistant to change.

CAUSAL FACTORS IN COMBAT STRESS PROBLEMSIn a combat situation, with the continual threat of injuryor death and repeated narrow escapes, a person's ordinarycoping methods are relatively useless. The adequacy andsecurity the person has known in the relatively safe anddependable civilian world are completely undermined. Ina study of psychiatric war casualties from data going backto the Boer War at the beginning of the twentieth century,Jones and Wessely (2002) pointed out that there is a con-stant relationship between the incidence of total killed andwounded and the number of psychiatric casualties in war.At the same time, we must not overlook the fact that mostsoldiers subjected to combat have not become psychiatriccasualties, although most of them have evidenced severefear reactions and other symptoms of personality disorga-nization that were not serious enough to be incapacitating.In addition, many soldiers have tolerated almost unbeliev-able stress before they have broken down, whereas othershave become casualties under conditions of relatively littlecombat stress or even as noncombatants-for example,during basic training.

In order to understand traumatic reactions to com-bat, we need to look at factors such as constitutional pre-disposition, personal maturity, loyalty to one's unit, andconfidence in one's officers, as well as at the actual stressexperienced.

Temperament Do constitutional differences in sensitiv-ity, vigor, and temperament affect a soldier's resistance tocombat stress? They probably do, but little actual evidencesupports this assumption. We have more information

about the conditions of battle that tax a soldier's emo-tional and physical stamina. Add other factors that oftenoccur in combat situations (such as severe climatic condi-tions, malnutrition, and disease) to the strain of continualemotional mobilization, and the result is a general lower-ing of a person's physical and psychological resistance toall stressors.

Psychosocial Factors A number of psychological andinterpersonal factors may contribute to the overall stressexperienced by soldiers and predispose them to breakdown under combat. Such factors include reductions inpersonal freedom, frustrations of all sorts, and separationfrom home and loved ones. Central, of course, are themany stresses arising from combat including constantfear, unpredictable and largely uncontrollable circum-stances, the necessity of killing, and prolonged harsh con-ditions. Personality (which is shaped by temperamentaldifferences beginning in infancy) is an important deter-minant of adjustment to military experiences. Personalitycharacteristics that lower a person's resistance to stress orto particular stressors may be important in determininghis or her reactions to combat. Personal immaturity,sometimes stemming from parental overprotection, iscommonly cited as making a soldier more vulnerable tocombat stress.

Worthington (1978) found that American soldierswho had trouble readjusting after they returned homefrom the Vietnam War also tended tohave had greater difficulties beforeand during their military servicethan soldiers who adjusted readily. Intheir study of the personality charac-teristics of Israeli soldiers who hadbroken down in combat during theYom Kippur War, Merbaum andHefez (1976) found that over 25 per-cent reported having had psychologi-cal treatment prior to the war.Another 12 percent had experienceddifficulties previously in the 6-dayIsraeli-Arab War of 1967. Thusabout 37 percent of these soldiershad clear histories of some personal-ity instability that may have predis-posed them to break down undercombat stress. On the other hand, ofthe other soldiers who broke down,over 60 percent had not shown ear-lier difficulties and would not havebeen considered to be at risk for suchbreakdown.

A background of personal mal-adjustment does not always make aperson a poor risk for withstandingcombat stress. Some people are so

accustomed to anxiety that they cope with it more or lessautomatically, whereas soldiers who are feeling severe anxi-ety for the first time may be terrified by the experience, losetheir self-confidence, and panic.

Sociocultural Factors Several sociocultural factors playan important part in determining a person's adjustment tocombat. These general factors include clarity and accept-ability of war goals, identification with the combat unit,esprit de corps, and quality of leadership.

An important consideration is how clear and accept-able the war's goals are to the individual. If the goals can beconcretely integrated into the soldier's values in terms ofhis or her "stake" in the war and the worth and importanceof what he or she is doing, this will help support the soldierpsychologically. Another important factor is a person'sidentification with the combat unit. In fact, the strongerthe sense of group identification, the less the chance that asoldier will break down in combat. Feelings of esprit decorps influence a person's morale and adjustment toextreme circumstances. Finally, if a soldier respects his orher leaders, has confidence in their judgment and ability,and can accept them as relatively strong parental or siblingfigures, the soldier's morale and resistance to stress arebolstered. On the other hand, lack of confidence or dislikeof leaders is detrimental to morale and to tolerance ofcombat stress.

Many factors may contribute to traumatic reactions to combat-constitutionalpredisposition, personal immaturity, compromised loyalty to one's unit, diminishedconfidence in one's officers, as well as the actual stress experienced. Thus, although combatsituations completely undermine a person's ordinary coping methods, some soldiers cantolerate great stress without becoming psychiatric casualties, while others may break downunder only slight combat stress.

It also appears that returning to an unaccepting socialenvironment can increase a soldier's vulnerability to post-traumatic stress. For example, in a I-year follow-up ofIsraeli men who had been psychiatric war casualties duringthe Yom Kippur War, Merbaum (1977) found not only thatthey continued to show extreme anxiety, depression, andextensive physical complaints, but also that in manyinstances they appeared to have become more disturbedover time. Merbaum hypothesized that their psychologicaldeterioration had probably been due to the unacceptingattitudes of the community; in a country so reliant on thestrength of its army for survival, considerable stigma isattached to psychological breakdown in combat. Becauseof this stigma, many of the men were experiencing notonly isolation within their communities, but also self-recrimination about what they perceived as failure on theirown parts. These feelings exacerbated the soldiers' alreadystressful situations.

The stressful events that veterans experience can alsohave a negative impact on their families when they returnhome. A recent study of the families of Dutch peacekeep-ing soldiers returning home from stressful assignmentsreported that partners and parents of former peacekeepersshowed signs of secondary traumatic stress responses(Dirkzwager, Bramsen, et aI., 2005).

Long- Term Effects ofPost-Traumatic StressIn some cases, soldiers who have experienced combatexhaustion may show symptoms of post-traumatic stressfor sustained periods of time (Penk, Rierdan, et aI., inpress). In cases of delayed post-traumatic stress, some sol-diers who stood up exceptionally well under intensive com-bat have experienced post-traumatic stress upon theirreturn home, often in response to relatively minor stressesthat they had handled easily before. Evidently, these soldiershave suffered long-term damage to their adaptive capabili-ties, in some cases complicated by memories of killingenemy soldiers or civilians as well as by feelings tinged withguilt and anxiety (Horowitz & Solomon, 1978).

The nature and extent of delayed post-traumaticstress disorder are somewhat controversial (Burstein,1985). Reported cases of delayed stress syndrome amongVietnam combat veterans are often difficult to relateexplicitly to combat stress, because these people may alsohave other significant adjustment problems. People withadjustment difficulties may erroneously attribute theirpresent problems to specific incidents from their past, suchas experiences in combat. The wide publicity given todelayed post-traumatic stress disorder has made it easy forclinicians to find a precipitating cause in their patients'backgrounds. Indeed, the frequency with which this disor-der has recently been diagnosed in some settings suggeststhat its increased use is as much a result of its plausibilityand popularity as of its true incidence.

In ReVIew~ What are the main differences between acute

stress disorder and post-traumatic stressdisorder?

~ What are the three stages of disastersyndrome? At which stage might PTSDdevelop?

~ What is controversial about the frequency ofdiagnosis of delayed PTSD?

PREVENTION ANDTREATMENT OF STRESSDISORDERS

If we know that extreme or prolonged stress can producemaladaptive psychological reactions that have predictablecourses, is it possible to prevent maladaptive responses tostress by preparing a person in advance to deal with thestress? When a predictable and unusually stressful situa-tion is about to occur, is it possible to "inoculate" a personby providing information ahead of time about probablestressors and suggesting ways of coping with them? Ifpreparation for battle stressors can help soldiers avoidbreakdowns, why not prepare other people to meet antici-pated stressors effectively?

This approach to stress management has been shownto be effective in cases where the person is facing a knowntraumatic event such as major surgery or the breakup of arelationship. In these cases a professional attempts to pre-pare the person in advance to cope better with the stress-ful event by teaching the person to develop more realisticand adaptive attitudes toward the problem. The use ofcognitive-behavioral techniques to help people managepotentially stressful situations or difficult events has beenwidely explored (Brewin & Holmes, 2003). This preventivestrategy, often referred to as stress-inoculation training,prepares people to tolerate an anticipated threat by chang-ing the things they say to themselves before the crisis. Athree-stage process is employed. In the first stage, infor-mation is provided about the stressful situation and aboutways people can deal with such dangers. In the secondstage, self-statements that promote effective adaptation-for example, "Don't worry, this little pain is just part of thetreatment"-are rehearsed. In the third stage, the personpractices making such self-statements while being exposedto a variety of ego-threatening or pain-threatening stres-sors such as unpredictable electric shocks, stress-inducing

films, or sudden cold. This last phase allows the person toapply the new coping skills learned earlier. We shall discussstress-inoculation training and the use of self-statementsin greater detail in Chapter 17. Unfortunately, one cannotbe prepared psychologically for most disasters or trau-matic situations, which by their nature are often unpre-dictable and uncontrollable.

Although a significant proportion of people in distress arereluctant to seek help for their symptoms, many people incrisis are in a state of acute turmoil and feel overwhelmedand incapable of dealing with the stress by themselves.They do not have time to wait for the customary initialtherapy appointment, nor are they usually in a position tocontinue therapy over a sustained period of time. Theyneed immediate assistance (Brown, Shiang, & Bongar,2003; Schnyder, 2005). Crisis intervention has emerged inresponse to a widespread need for immediate help forindividuals and families confronted with especially stress-ful situations-be they disasters or family situations thathave become intolerable (Butcher & Dunn, 1989;McNally, Bryant, & Ehlers, 2003; Ritchie & Owens, 2004).But there are several approaches to treating the symptomsof PTSD: (1) short-term crisis therapy involving face-to-

face discussion, (2) post-disaster debriefing sessions,(3) direct-exposure therapyfor those whose PTSDsymptoms persist, (4) tele-phone hotlines, and (5) psy-chotropic medications.

Short-term crisis therapy is geared tohelp the individual or family gainclarity, form a plan of action, obtainsupport and reassurance, and moveforward through the immediateproblem. Over the course of no morethan six sessions, the therapist tries toprovide as much help as the individualor family needs and witt accept. In thewake of the September 11, 2001,

terrorist attacks, many people foundthemselves in a crisis situation andsought psychological assistance tocope with the disaster.

SHORT-TERM CRISISTHERAPY Short-termcrisis therapy is of briefduration and focuses on theimmediate problem withwhich an individual orfamily is having difficulty.Although medical problemsmay also require emergencytreatment, therapists areconcerned here with per-sonal or family problems ofan emotional nature. In suchcrisis situations, a therapistis usually very active, helpingto clarify the problem, sug-gesting plans of action, pro-viding reassurance, andotherwise providing neededinformation and support.

If the problem involvespsychological disturbance

in one of the family members, emphasis is usually placed onmobilizing the support of other family members. Often thisenables the person to avoid hospitalization and a disrup-tion of family life. Crisis intervention may also involvebringing other mental health or medical personnel intothe treatment picture. Most individuals and families whocome for short-term crisis therapy do not continue in treat-ment for more than one to six sessions.

A central assumption in crisis-oriented therapy is thatthe individual was well functioning psychologically beforethe trauma. Thus therapy is focused only on helping theperson through the immediate crisis, not on "remaking"her or his personality. As a central strategy, traumatizedvictims are provided emotional support and are encour-aged to talk about their experiences during the crisis(Cigrang, Pace, & Yasuhara, 1995).

POSTDISASTER DEBRIEFING SESSIONS Those whoappear to function well at a disaster site may experience dif-ficulties after the immediate crisis has subsided and theyhave returned to their families and their normal duties.Even experienced disaster workers who are well trained andeffective at the site can be affected later by the pressures andproblems experienced during the disaster (Flannery, 2004).One approach to helping people who have been involved ina disaster is to arrange debriefing sessions to allow them todiscuss their experiences with others, usually shortly afterthe trauma has subsided. To "unwind" in a psychologicallysafe environment and to share one's experience of the dis-aster are universal needs of people following a traumaticsituation (Raphael & Wooding, 2004).

A widespread movement has evolved over the past 20years to provide (even to mandate) debriefing sessions forthose who have experienced a disaster (Zeev, Iancu, & Bod-ner, 2001). Such sessions are not always provided by men-tal health professionals. In fact, a small industry has sprungup to provide debriefing services, and disaster scenes areoften swarmed by service providers-most well meaningbut many with little or no mental health training. Furtherconfusing the aftermath of a disaster are non-mentalhealth "intruders:' such as attorneys who are seeking toenlist potential litigants for lawsuits. For example, at theairport in Detroit, following the Northwest Airlines crashin 1987, a man dressed in the attire of a priest was provid-ing counseling services to family members and airline per-sonnel for several days following the accident. Employeesbecame suspicious when he told one of the counselees thathe had been at the airport for several days and needed totake some time off to go see his wife. It turned out that hewas not a priest at all but a front man for a law firm. He hadbeen passing out business cards for the law firm to everyperson he counseled.

DIRECT-EXPOSURE THERAPY One behaviorally ori-ented treatment strategy that has been used effectively forPTSD clients, particularly those with delayed-onset or

Crisis Intervention andAirline Disasters

There are many situations in which crisis inter-vention is necessary, but one crisis in particularrequires additional effort in counseling-air-line crashes. The immediate consequences ofan air crash are devastating. Survivors typi-

cally have traumatic responses to the accident that impairtheir immediate functioning and place great demands ontheir psychological adjustment for weeks after the disas-ter. Family members of victims often experience great psy-chological trauma as well; they may need to makeextensive changes during their loved one's lengthy recov-ery period, or they may need to make major life changesto adjust to their loved one's death. Even rescue personnelcaught up in dealing with the aftermath of an airline disas-ter may suffer from post-traumatic stress disorder (Davis& Stewart, 1999).

Like natural disasters, airplane crashes are suddenand unexpected, and they are usually quite chaotic. There islittle of the sense of community, however, that characterizesthe response to many natural disasters. In fact, air crashesusually involve considerable blame and anger toward airlinecompanies, which can aggravate or intensify the emotionalreactions of survivors even months after the crash.

Most airports are required to have a disaster plan thatincludes rescue and evacuation procedures to deal with anairplane crash. Some airport disaster plans have alsoincorporated a psychological support program to provideemergency mental health services to survivors, the familymembers of crash victims, and rescue workers (Butcher &Dunn, 1989; Carlier, Lamberts, & Gersons, 1997).

How Crisis Counselors Help During Air DisastersCrisis intervention supplied in the immediate aftermath ofa disaster can reduce the emotional distress experiencedand can result in a more effective future psychological

adjustment (Butcher & Hatcher, 1988). A crisis counseloroffers objective emotional support and tries to provide along-term perspective-to allow victims to see that there ishope of surviving psychologically. Disasters are always fol-lowed by periods of confusion and misinformation. Oneimportant role of the mental health professional in disasterresponse efforts is to obtain, decipher, and clearly commu-nicate to victims the most accurate picture of the situationobtainable at the moment. Finally, a crisis counselor pro-vides practical suggestions to promote adaptation. In anextreme crisis, people often lose perspective and "forget"that they are usually quite effective in dealing with lifeproblems.

Air Disasters and Telephone Hotline CounselingAfter an air disaster, considerable psychological turmoilprevails among passengers and crew members. This stateof tension can result in demoralization and negative behav-ior such as absenteeism from work, excessive drinking,and morale problems. An effective way to deal with thispsychological uncertainty and reduce the negative atmos-phere following an air disaster is to provide telephonecounseling services for all those who feel the need to dis-cuss their concerns, be they airline employees or the fami-lies of passengers.

Debriefing SessionsDebriefing sessions are typically conducted in groups afterthe intensity of the immediate crisis has subsided. Debrief-ing sessions allow the participants in the disaster (such asaid workers) to express their feelings and emotions and tolearn what people in similar situations have experienced.These sessions are effective in reducing the negativeimpact of people's emotional reactions to traumatic events.

chronic PTSD, is direct-therapeutic exposure (Taylor,2003). In this approach, the client is exposed or reintro-duced to stimuli that have come to be feared or to be asso-ciated with the traumatic event (McIvor & Turner, 1995).This procedure involves repeated or extended exposure,either in vivo or in the imagination, to objectively harm-less but feared stimuli for the purpose of reducing anxiety(Foa & Rauch, 2004; Foa, Zoellner, et aI., 2002). Exposureto stimuli that have come to be associated with fear-producing situations might also be supplemented by otherbehavioral techniques in an effort to reduce the symptomsof PTSD. For example, the use of traditional behavioraltherapy methods such as relaxation training and assertive-

ness training might also be found to be effective in helpinga client deal with anxiety following a traumatic event.

TELEPHONE HOTLINES Today, most major cities in theUnited States and many smaller ones have developed someform of telephone hotline to help people undergoing peri-ods of severe stress. In addition, there are specific hotlinesin many communities for rape victims and for runawayswho need help.

As with other crisis intervention approaches, a personhandling hotline calls must rapidly assess what is wrongand how bad it is. Even if an accurate assessment is possibleand the hotline worker does everything within his or her

power to help the caller, a distraught person may hang upwithout leaving any name, telephone number, or address.This can be a disturbing experience for the hotline coun-selor. Even in less severe cases, of course, the hotline workermay never learn whether the caller's problem has beensolved. In other instances, however, the caller may be per-suaded to come in for counseling, making more personalcontact possible.

PSYCHOTROPIC MEDICATIONS As we have seen, per-sons experiencing traumatic situations usually reportintense feelings of anxiety or depression; numbing, intrusivethoughts; and sleep disturbance. Several medications can beused to provide relief for intense PTSD symptoms (see theUnresolved Issues section of this chapter). Antidepressants,for example, are sometimes helpful in alleviating PTSDsymptoms of depression, intrusion, and avoidance (Mar-shall & Klein, 1995; Shalev, Bonne, & Eth, 1996). However,because the symptoms can fluctuate over a brief period oftime, careful monitoring of medications and dosage isrequired. The use of medication tends to focus on specificsymptoms-for example, intrusive, distressing symptomsor nightmares; images of horrible events; startle reaction;and so forth (see Chapter 17).

Challenges in StudyingCrisis Victims

typically for immediate intervention and cannot be usedfor long-term care or evaluation research (Pfefferbaum,Call, & Sconzo, 1999).

What We Are Learning aboutCrisis InterventionResearch on the efficacy of crisis intervention is usuallydesigned and implemented after the fact. In some cases, itgets under way months after the disaster occurred and isconstructed with available resources in a post-hoc fashion.Even so, a number of studies have provided valuable infor-mation. For example, Brom, Kleber, and Defares (1989)conducted a controlled study of the effectiveness of brieftherapy with people experiencing PTSD and found thattreatment immediately following the traumatic event signif-icantly reduced their PTSD symptoms. Sixty percent of thetreated persons showed improvement, whereas only 26 per-cent of the untreated group improved. Treatment did notbenefit everyone, however, and some people maintainedtheir PTSD symptoms even after therapy was terminated.

The disaster response strategy that has received themost attention over the past few years and is presentlyembroiled in controversy is postdisaster debriefing. Somebelieve that postdisaster counseling (much of which is

conducted by people who are notmental health professionals) shouldbe mandated for disaster victims inorder to provide a quick fix (Conlon &Fahy, 2001). However, single debrief-ing sessions have not been demon-strated to reduce psychological distressor to prevent the development ofstress-related disorders. In fact, someevidence suggests that the disaster vic-tims who underwent debriefing faredworse than controls (Mayou, Ehlers, &Hobbs, 2000).

On the other hand, some investi-gators have reported that debriefingsessions following a disaster areeffective. Chemtob, Tomas, Law, andCremniter (1997), for example,explored the use of debriefing sessionsand found this approach to be effec-tive in reducing the emotional reac-tions to traumatic events. In anotherstudy, firefighters in Australia who par-ticipated in crisis debriefing after theirordeal perceived the intervention asbeneficial in reducing their stress(Regehr & Hill, 2000). Everly, Boyle,and Lating (1999), after surveying the

existing outcome literature on debriefing and conducting ameta-analysis of ten published studies, concluded thatdebriefings are effective in alleviating the effects of stress.

In order to be effective and valid, psy-chological research conducted underfield conditions must be carefullyplanned and organized. Research onthe victims of a disaster is extremelydifficult to implement for a number ofreasons. It is virtually impossible tohave an ideal, well-controlled, andwell-funded experiment set up "await-ing a disaster." One cannot predictnatural disasters such as a sudden tor-nado or fire, so it is difficult to havequalified staff ready to conductresearch. Sound psychological researchrequires careful definition of the vari-ables and meticulous management ofthe details in order to ensure thatappropriate and effective measures areimplemented. The variables we areinterested in studying, such as the vic-tims' grief response, are typically diffi-cult to assess, and the extraneousconditions are difficult if not impossi-ble to control. Often in disaster situa-tions (for example, airplane crashes),therapy sessions are conducted in noisy, makeshift quarterssuch as crew lounges, hallways, and gate areas. Moreover,federal disaster funds that might be made available are

The events of September 11, 2001,produced an intense period ofgriefforfamilies and friends of the victims, rescueworkers. and people around the worldwho witnessed the attacks on television.Following the attacks. many people feltthe need to tell the same story about thedisaster again and again as a way toreduce anxiety and to desensitizethemselves to the traumatic experience.

Hurricane Katrina left tens of thousands of people in dangerousand stressful circumstances. Here several hurricane victimsattempt to attract the attention of rescuers.

In a thoughtful review) Deahl (2000) concluded that

demonstrating the efficacy of debriefing presents a major

challenge to investigators and that the controversy is not

likely to be resolved soon.

In ReVIew~ What strategies are useful for preventing or

reducing maladaptive responses to stress?~ Describe crisis intervention therapy. How is

this treatment approach different frompsychotherapy for other mental healthconditions?

~ In what way are medications used in treatingindividuals in crisis?

~ Describe the current controversy surroundingthe use of "debriefing interventions."

Psychotropic Medication in theTreatment of PTSD

ost authorities accept the view that PTSDresults as a human response to extremelystressful events-even though the criteriafor diagnosis differ somewhat between thetwo major diagnostic systems, DSM-IV and

I(D-l0 (Shalev) 2001). In both systems, however, exposureto an extreme stressor is one of the criteria for diagnosis. Thetreatment for PTSD has characteristically involved social orbehavioral intervention-that is, primarily the use of inter-ventions to alter the stressful situation or the individual'sresponse to the stressor and to promote future adaptation(Hammer, Robert, & Frueh, 2004). Over the past few years,psychotropic medications have been used increasingly torelieve the symptoms of PTSD. For example, two recent stud-ies have found that risperidone is effective at reducing thesymptoms of chronic post-traumatic stress disorder (Bart-zokis, Lu, et aI., 2005; David, De Faria, et aI., 2004).

The symptoms of PTSD, whatever their cause, can beextremely disabling and may leave a person unable to dealeffectively with everyday demands. In some cases, the symp-toms may be so intense and disabling that medication is pre-scribed to enable the patient to deal with the situation.Several medications are used to provide relief for intensePTSD symptoms. For example, antidepressants are some-times considered helpful in improving symptoms of depres-sion, intrusion, and avoidance (Pearlstein, 2000; Shalev,Bonne, & Eth, 1996).

Berlant (2001) recently reported on a novel use of thedrug topiramate, an anti-epileptic or seizure medication, toreduce a patient's intrusive memories and nightmares, allow-ing her to deal more effectively with troubling events:

Ms. A., a 35-year-old woman, presented with occa-sional "post-traumatic dreams" related to the death of

(continued)

her child 15 years previously, in addition to irritability,depressed mood, impulsivity, and marijuana abuse.Fluoxetine (an antidepressant), which had providedsome relief for 5 years, had stopped helping. She hadbeen unable to give up cannabis use for 15 years, find-ing that it helped suppress her nightmares. Precedingthe loss of her child, Ms. A. had grown up in a house-hold where she remembered feeling terrified and hid-ing when her parents argued and threatened to killeach other. At the age of 12 years, she was molested byher aunt's husband. When she sought her aunt's inter-vention, Ms. A. was not believed. At 13 years, her fatherdied, leaving her in the care of a "hateful mother," whoabandoned her and her sister to live on the street andlater with relatives. As she grew older, she found thatsex, alcohol, and marijuana provided her with somehappiness.

At 20 years, Ms. A. became pregnant, only to lose thechild to neonatal herpes at the age of 1week. Shedescribed in vivid detail the experience of watching thebaby's skin erupt with lesions and then watching as thebaby went into cardiac arrest while being attended in anemergency room. She refused to be ushered from theresuscitation room, thereby subjecting herself to view-ing the doctor's interventions, which included the futileinsertion of a "7-inch needle into the baby's heart."Thereafter, she found herself besieged by nightmares ofthe death and by intrusive memories of the nightmares.She used alcohol and marijuana to suppress thesesymptoms for 15 years but finally decided that shewanted to stop using addictive drugs and come to termswith her problems.

Within 10 days of her stopping drugs and alcohol,and despite the introduction of sertraline, nightmaresreemerged every few days, accompanied by almost dailyintrusive reexperiencing of the nightmares. Especiallytroubling were the dreams of seeing her baby's corpserotting in the ground and calling for her. Accompanyingthese symptoms were severe startle responses, socialavoidance, and very low social functioning. (pp. 60-61)

Berlant (2001) noted that after topiramate was pre-scribed, Ms. A. reported that her nightmares had become lessintense and that her dreams were difficult to remember andwere not "grossly bloody," as they had been before. She alsofelt that her emotional reaction to the dreams had lessened.There were no longer any daytime intrusions, and the startlereaction had not recurred. She was maintained on topiramatefor 30 days, after which the dosage was decreased. The night-mares recurred with the lower dosage level. The higher

dosage level was reinstated, and there were no additionalnightmares or intrusive memories.

Other antidepressant medications have been used intreating PTSD symptoms. Examples include trazodone(Warner, Dorn, & Peabody, 2001); nefazodone (Davis et aI.,2000); fluoxetine (Davidson, Payne, et aI., 2005); and sertra-line (Comer & Figgitt, 2000). These drugs are targeted atreducing specific symptoms such as intrusive, distressingthoughts or nightmares; images of horrible events; startlereaction; and so forth. Vargas and Davidson (1993) concludedthat psychotherapy administered along with medications wasmore effective in improving PTSD symptoms than medica-tions taken alone. In general, most authorities agree thatmedications do not provide a quick fix to treatment oftrau-matized patients.

The idea that an environmentally or socially induced dis-order can be treated biologically by altering a person's mentalstate through medications may seem incongruous. Also, theuse of medications could have some unwelcome conse-quences. Medications might, for example, suppress the nat-ural "warning signs" (the anxiety symptoms accompanyingdistress) and lull the person into a false sense of havingescaped the effects of the traumatic experience. That miscon-ception could lower her or his ultimate adaptive capabilities.Interestingly, medications actually may reinforce one of themain symptoms of PTSD-avoidance-by allowing the personrespite from the intense symptoms. As Ehlers (2000) pointedout, "Avoidance is one of the main symptoms of PTSD, and itcan thus take years for the person to seek help for this condi-tion. It is important for clinicians to bear in mind [that] eventhose who seek help may find it hard to talk about the trau-matic experience, and may show signs of avoidance such asirregular attendance or failure to disclose the worst momentsof the trauma initially ... " (p. 768).

Finally, the use of tranquilizing medications can pro-mote an overreliance (psychological if not physiological) onmedication.

The practitioner cannot simply prescribe medications andmonitor their effect in brief follow-up visits. Rather, in the caseof severe PTSDsymptoms, the practitioner needs to integrateany medications carefully into the psychological and environ-mental treatment efforts. Recovery from severe PTSD oftenrequires a drastic life reorientation. Overmedicated, tranquil-ized victims might feel less stressed but may not recognize theurgency of establishing new life circumstances.

In summary, a variety of psychotropic medications areincreasingly being used in the treatment of traumatizedpatients. It is important to keep in mind that we do not yetknow to what extent medications are effective in the treatmentof PTSD symptoms (Ehlers, 2000; Jaranson, Kinzie, et aI., 2001).

~ Many factors influence a person's response tostressful situations. The impact of stress depends notonly on its severity but also on the person'spreexisting vulnerabilities.

~ A person's response to conflict situations may beviewed differently, depending on whether theconflicts are approach-avoidance, double-approach,or double-avoidance.

~ A wide variety of psychosocial stressors exist, and aperson can respond to them in different ways; forinstance, a person may react with task-oriented ordefense-oriented responses.

~ The DSM-IV-TRclassifies people's problems inresponse to stressful situations under two generalcategories: adjustment disorders and post-traumaticstress disorder (which is included with the anxietydisorders).

~ Several relatively common stressors (prolongedunemployment, loss of a loved one through death,and marital separation or divorce) may produce agreat deal of stress and psychological maladjustment,resulting in adjustment disorder.

~ More intense psychological disorders in response totrauma or excessively stressful situations (such asrape, military combat, imprisonment, being heldhostage, forced relocation, or torture) may becategorized as post-traumatic stress disorder.

~ PTSDcan involve a variety of symptoms includingintrusive thoughts and repetitive nightmares about

acute stress disorder (P. 158)

adjustment disorder (P. 154)

coping strategies (P. 144)

crisis (P. 147)

crisis intervention (P. 147)

debriefing sessions (P. 172)

defense-oriented response (P. 150)

disaster syndrome (P. 158)

the event, intense anxiety, avoidance of stimuliassociated with the trauma, and increased arousalmanifested as chronic tension, irritability, insomnia,impaired concentration and memory, anddepression.

~ If the symptoms begin 6 months or more after thetraumatic event, the diagnosis is delayed post-traumatic stress disorder.

~ Many factors contribute to a breakdown underexcessive stress, including the intensity orharshness of the stress situation, the length ofthe traumatic event, the person's biologicalmakeup and personality adjustment before thestressful situation, and the ways in which theperson manages problems once the stressfulsituation is over.

~ In many cases the symptoms recede as the stressdiminishes, especially if the person is givensupportive psychotherapy. In extreme cases,however, there may be residual damage or thedisorder may be of the delayed variety, not actuallyoccurring until some time after the trauma.

~ Several approaches to treating the symptoms of PTSDare in use today: short-term crisis therapy involvingface-to-face discussion, debriefing sessions withvictims of disaster, direct-exposure therapy for thosewhose PTSDsymptoms persist, telephone hotlines,and psychotropic medications to relieve symptoms ofPTSD.

distress (P. 144)

eustress (P. 144)

general adaptation syndrome(p.151)

personality or psychologicaldecompensation (P. 151)

post-traumatic stress disorder(PTSD) (p.157)

psychoneuroimmunology (P. 153)

stress (P. 144)

stress-inoculation training (P. 171)

stress tolerance (P. 148)

stressors (P. 144)

task-oriented response (P. 150)