Applied History of Psychology/Perspectives on Psychological Trauma

Introduction to Perspectives on Psychological Trauma

It has been said that whatever doesn’t kill us makes us stronger. A few people live through horrible events without experiencing much fear, but most of us react with feelings of horror and helplessness. Psychological trauma occurs in the wake of an unexpected event that is so unpleasant and shocking that the human mind and body react in an autonomic defensive manner (Thornet, 2000). For some people, surviving severe traumatic events leaves them depressed, anxious, and with other emotional scars such as Post Traumatic Stress Disorder (PTSD).

By definition, PTSD includes episodic re-experiencing of traumatic events, usually in the form of dysphoric memories. Because these memories are vivid, frightening and unexpected, they have secondary effects, causing sufferers to doubt their sanity, their progress in recovery and their fundamental sense of security (Ochberg, 1998). The original traumatic experience had elements of terror, horror, and/or helplessness, and persistent episodes of traumatic memory continue and compound such elements (Ochberg, 1998). Recent findings have indicated PTSD prevalence rates of 5% and 10% respectively among American men and women (Kessler, Sonnega, Bromet, Hugues, & Nelson, 1996).

The key to understanding the scientific basis and clinical expression of PTSD is the concept of “trauma” (Friedman, 1997). PTSD is unique among other psychiatric diagnoses because of the great importance placed upon the etiological agent, the “traumatic stressor” (Herman, 1992). Thus, traumatization is seen as being caused by the event, not because of some failing or weakness in the person. In fact, one cannot make a clinical diagnosis of PTSD unless the client has actually met the “stressor criterion”. Along with the diagnostic criteria of exposure to a “traumatic event” are symptoms from each of the three symptom clusters: intrusive recollections, avoidant/numbing symptoms and hyperarousal symptoms (APA, 1994). A fifth criterion concerns the duration of the symptoms (APA, 1994). The duration criteria for diagnosis of PTSD when the above criteria have been met is one month (APA, 1994).

Not only is PTSD typified by the automatic, involuntary symptoms such as flashbacks, intrusive thoughts and autonomic hyperarousal, but also consciously mediated attempts to make meaning of the trauma experience(s) (Clark & Ehlers, 2000). The automatic and involuntary symptoms are said to represent conditioned responding to environmental triggers associated with the trauma (Clark & Ehlers, 2000). Much less is known about the origins and consequences of victims’ efforts to understand their trauma(s) or about how best to treat the symptoms associated with personal beliefs about the trauma (Meichenbaum, 1994).

In children, an important issue in the experience of trauma is its effect on the attachment system and developing brain function.

Earliest writings on trauma cases

Humankind has never been without traumatic events. The earliest writings of history contain evidence of the manifestation of psychological symptoms related to distressing experiences. Over time theories regarding the symptoms, causes, and treatment resulting from trauma have greatly varied.

Initially, only women were believed to be inflicted by symptoms that had no physical explanation, such as sudden loss of sight, loss of ability to walk, or uncontrollable shaking. The earliest indication of these symptoms was recorded on an Egyptian papyrus from 1900 BC, which attributed the disorder to a wandering uterus. The use of the term, hysteria, to describe this constellation of symptoms dates back to Hippocrates (430-367 B.C.) who labeled the condition for its Greek meaning of uterus. Since this condition was only documented in women, his prescribed cure for the afflictions caused by a wandering uterus was marriage. Of note, trauma is a term widely used in psychology and its meaning is derived from the Greek word for wound. The term emerged into the neurological and psychiatric vocabulary in the 1860’s and 1870’s. Previously, the term trauma had been reserved for the description of physical wounds and had been documented in the surgical medicine literature.

Anton Mesmer (1734–1815) was the first to explain hysteria in a physiological way. He believed that hysteria was a direct result of a disturbed distribution of the magnetic fluid present in all humans. He appears to have been the first to document the possibility that hysterical symptoms could be present in men and women. Mesmer’s treatment for hysteria involved touching his patients with rods, which he said transmitted a magnetic force called animal magnetism from his body to the patient. He believed that this force of animal magnetism was capable of rearranging the patient’s fluids to result in healthy functioning, and thereby curing the condition of hysteria. With our knowledge today, it is widely believed that Mesmer’s approach was a predecessor of hypnotism due to his convincing manner of describing his techniques to his patients and his strong suggestions of recovery. Although Mesmer’s techniques resulted in improvement and documented cures of many of his patients, his theories and techniques were not respected by other health professionals at the time.

With the development of the railroad in the mid 1800’s, there was also an increase in accidents and death with this initially dangerous mode of transportation. Lerner (2003) found statistics of injuries related to the railway in the United States in 1889: one out of every 117 train workers was killed and one out of every 12 workers was injured. In addition, passengers and bystanders were involved in train collisions and derailings, which in that time were common. Some accident victims seemed to complain of common symptoms such as headaches, dizziness, paralysis, and general disinterest and listlessness with no apparent physical cause. In 1866, an English physician, John Eric Erichsen (1818–1896) published several cases of this condition and coined the term “railway spine”. In addition to the abovementioned symptoms, he wrote about memory loss, confusion, diminished business aptitude, ill temper, sleep disorders, sensory impairment, attitude changes, loss of motor power, numbness and sexual impotence. Although these symptoms paralleled those of hysteria, Erichsen chose the new label of railway spine since it was previously believed that only women were inflicted with hysteria and most of his patients related to the railroad were men.

With increasing numbers of mental health diagnoses related to trauma, treatment for these symptoms was in high demand. Jean-Martin Charcot (1825–1893) was a neurologist who believed that hypnotism was of value in treating hysterics. Originally, his theories on hysteria were somatic in nature. Over time, he adjusted his original theories to include psychological factors. Additionally, in 1882, he began treating cases of hysteria in male patients, which he reported were growing in large numbers. He described symptoms in these males as motor and sensory disturbances due to railroad accidents, workplace accidents, and service in war. He believed that these symptoms were directly related to a traumatic stimulus in those individuals who had an inherited, constitutional disposition.

As stated earlier, symptoms of hysteria were not initially believed to be inflictions of men. However, with men fighting in the frontlines of World War I where they took the lives of the opposition, witnessed violent deaths of their fellow soldiers, and often narrowly escaped death themselves, it is not surprising that many soldiers began demonstrating symptoms of what was then know as hysteria. Soldiers were documented as suffering from symptoms such as debilitating shakes, stutters, tics and tremors, disorders of sight, hearing, and gait (Lerner, 2003). Although there is evidence of other problems during other wars, the sheer number of soldiers with these inflictions caught medical authorities unprepared and therefore drew much attention. Since it was thought unfitting to diagnose these men with a woman’s illness, new labels were created to describe these combinations of symptoms as listed earlier. Many features of what is now called post-traumatic stress disorder were well-described in literary form during this time, such The Red Badge of Courage. However, it wasn’t until World War II that there was a creation of a formal diagnostic category. World War II had brought together soldiers, psychiatrists and other medical personnel, and they discovered that they did not always have a common vocabulary to discuss syndromes and diagnoses.

After World War II ended, the Veterans Administration (VA) developed a diagnostic manual. This provided incentive for the American Psychological Association (APA) to create its own first manual. Thirteen years after his Freud’s death, the American Psychological Association (APA) published its first diagnostic and statistical manual (DSM-1) in 1952 and re-wrote his conceptualization of traumatic neurosis for Gross Stress Reaction. During the post-war era and after there was a rise in systematic investigations of things such as the consequences of exposure to death camps and experiences of prisoners of war, as well as nonmilitary stressors such as mass catastrophes, such as fires, earthquakes and plane crashes (Adler, 1943; Andreasen, Hartford & Norris, 1971).

For reasons unknown, but perhaps because of the early links between military combat and stress disorders, Gross Stress Reaction was somehow dropped from DSM-II (Andreasen, 2004). That manual was written when the United States was not engaged in any major war. However, the scientific study of the consequences of stress continued, particularly in the area of consequences of severe burn injuries (Andreasen, 2004).

After the Vietnam War, the U.S. contained another wave of young men who had been traumatized in combat. There was no official diagnosis to give them, and therefore, no coverage for treatment. American veterans lobbied the APA to construct a diagnosis of “Post-Vietnam Syndrom” to recognize the long-term psychological damage incurred by soldiers in combat, in order to pave the way for therapeutic services. Recognizing the long history of the syndrome proposed, as well as the fact that it frequently occurred in traumatized civilians as well, and being rooted in the extensive literature on stress disorders already available at the time, the APA came up with Post-Traumatic Stress Disorder as an operational diagnosis in DSM-III. Criteria specified for the new diagnosis included an initial stressor that would evoke distress in almost anyone (Criterion A), a time frame, and a list of “symptoms”.

The diagnosis began to be used widely and its application broadened steadily. For example, it began to be used for victims of childhood sexual abuse who developed traumatic stress symptoms much later in life. The requirement that the stressor be outside the range of normal human experience was sometimes reinterpreted to include less severe stressors (Andreasen, 2004). In 1987, the criteria for PTSD was reworked in the DSM-III-R. The veteran issues again faded in importance, while feminist practitioners took a special interest in PTSD.

Feminist therapists began lobbying the APA to alter the definition of PTSD so that more of their clients would fall under its auspices (Burstow, 2005). In 1994, PTSD was revised in DSM-IV such that Criterion A now stated that the person had to either experience, witness or be confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others. The person’s response must have involved intense fear, helplessness or horror and caused clinically significant distress and impairment in social, occupational or other important areas of functioning. This incorporated the concept of “vicarious traumatization” (i.e. emergency services, rescue workers, etc.). The DSM-IV also added back what was formerly called Acute PTSD, which had been dropped from DSM-III-R, under a new name of Acute Stress Disorder (ASD). In 2000, the DSM-IV-TR PTSD reformulated such that it is not required that the traumatizing event be outside the range of normal experience and explicitly makes room for common events such as childhood sexual abuse. Currently, trauma is of particular interest, at a time when the entire world is aware of the potential for terrorism to strike – a stressor of great magnitude that could strike at any time and anywhere. This is also a time when the U.S. is seeing the return of many traumatized young soldiers returning from the wars in Iraq and Afghanistan. Unfortunately, the present state of our world is likely going to provide many more opportunities to study stress reactions, and the diagnoses of ASD and PTSD are likely here to stay.

Timeline of Documented Cases of Trauma (Parry-Jones and Parry-Jones, 1994)

• 1860: Spinal concussion, railway spins, irritable heart
• 1870: Soldier’s heart, cardiac weakness
• 1880: Traumatic shock, traumatic neurosis, hysterical hemianaesthesia, spinal irritation, railway brain, and nervous shock
• 1890: Anxiety neurosis, psychical trauma
• 1910: Traumatic neurosis, shell fever, irritable heart of soldiers, mental shock, war shock, shell shock, neuro-circulatory asthenia, disordered action of the heart, and war psychoneurosis
• 1930: Cardiac/war neurosis
• 1940: Battle fatigue/combat exhaustion, effort syndrome
• 1980: PTSD

Assessment of Trauma and PTSD

Assessment Instruments

Frueh, Elhai, & Kaloupek (2004) provided a list of measures of trauma and suggest that these measures can be classified within the following four categories:

1. Trauma exposure measures

• Traumatic Life Events Questionnaire
• Traumatic Stress Schedule

2. Symptom-referenced PTSD measures

• PTSD Symptom Scale
• PTSD Checklist

3. PTSD diagnostic measures based on standard interview formats

• Structured Clinical Interview for DSM-IV (SCID) PTSD Module
• Clinician-Administered PTSD Scale (CAPS)

4. Psychometrically derived PTSD measures

• Mississippi Combat PTSD Scale
• Minnesota Multiphasic Personality Inventory-2 (MMPI-2)

Treatment throughout history

Exposure Therapy

Keane and his colleagues first applied Exposure Therapy (ET) to the treatment of PTSD in the form of single-subject designed studies to document the effects of exposure to memories of traumatic events (Black & Keane, 1982; Fairbank & Keane, 1982; Kaloupek & Keane, 1982). Significant reductions in trauma symptoms, anxiety, and other related symptoms were found as a function of ET interventions. This preliminary work led to the development of randomized clinical trials that compared Imaginal Based ET to the less intensive treatment of Anxiety Management Therapy (AMT) and wait-list controls. The results of this study were clear. Compared to the wait-list condition and AMT, those clients receiving ET showed significant reductions on standard psychometric instruments and on clinician ratings of symptoms, and changes were maintained at a 6-month follow-up (Caddell, Fairbank, Keane & Zimmering, 1989).

More recently, many studies have appeared in the literature comparing the effectiveness of ET to Cognitive Therapy (CT). For example, Barrowclough, Faragher, Graham, Pilgrim, Reynolds, Sommerfield & Tarrier (1999) examined the effectiveness of ET and CT in the treatment of outpatients with PTSD stemming from many different traumatic events. Both groups manifested significant improvements that were maintained at a 6-month follow-up. No significant differences were found between the two treatments and outcomes were favorable for both groups. Similar results have also been found by other authors, such as Astin, Nishith, and Resick (2000) who reported on the comparison of ET and CT in the treatment of rape-related PTSD. In general, the two treatments have been found to be equally effective and more effective than wait-list control groups.

Cognitive-Behavioral Therapy

Cognitive Therapy (CT) involves addressing key cognitive distortions found among people who have been traumatized. In particular, the interventions are designed to address difficulties in safety, trust, power, self-esteem, and intimacy in the lives of survivors. Combination treatments that include an array of cognitive-behavioral strategies have had intuitive clinical appeal because they address multiple problems that people with PTSD may exhibit, as well as incorporating techniques that have empirical support in the literature. For example, Fecteau and Nicki (1999) examined a treatment package of 8-10 sessions including trauma education, ET, cognitive restructuring and guided behavioral practice and compared outcomes to wait-list controls. The results of the intervention were successful as measured by clinical ratings, self-report questionnaires, and a laboratory-based psychophysiological assessment procedure. The results were clinically, as well as statistically, significant and the treatment effects were maintained at 6-month follow-up.

Emotion-Focussed Therapy

Emotion-Focused Therapy (EFT) has also shown itself to be effective in helping clients deal with the sequelae of trauma. For example, Greenberg and Paivio (1995) reported clinically meaningful, stable gains for most clients treated with process-experiential therapy (a type of EFT), and that these gains were significantly greater improvements as compared to a psychoeducational group. In addition, Nieuwenhuis and Paivio (2001) investigated a 20-session EFT applied to adults with PTSD symptoms as a result of unresolved childhood abuse issues. Clients in the treatment group were compared to a wait-list control group. EFT clients showed significantly greater improvements than wait-list controls on measures of general anxiety and PTSD symptoms, global interpersonal problems, self-affiliation, and resolution of issues with abusive others. Several other studies have also shown EFT to be effective in treating PTSD symptoms (Soulier, 1995; Clarke, 1993; Davis, Elliott & Slatick, 1998). These studies are more than adequate to support the conclusion that EFT is an efficacious and specific treatment for people suffering the effects of trauma (Elliott et al., 2003). I would argue that EFT works well with clients dealing with PTSD symptoms because often such clients have not been able to develop the skills necessary to process their emotions due to past trauma and/or early attachment experiences. EFT can help increase clients’ emotional intelligence and improve their emotional processing skills so they can better regulate their emotions (Watson, 2006). Clients move towards healing and wholeness in their lives as they learn to become aware of, label, express and reflect upon their emotions so that they may move more productively towards fulfillment of their needs, values and goals (Watson, 2006).

Current understanding of early trauma: Neurosciences and attachment

Key Figures

• Pierre Janet published L'Automatisme Psychologique, which was his first work to deal with how the mind processes traumatic experiences. "Janet claimed that vehement emotions interfere with proper appraisal and appropriate action. Failure to confront the experience fully leads to dissociation of the traumatic memories and their return as fragmentary reliving experiences, feeling states, somatic sensations, visual images, and behavioral reenactments. A century later, Janet still provides an unsurpassed framework for integrating current knowledge about the psychodynamic, cognitive, and biological effects of human traumatization" (Brown, van der Hart & van der Kolk, 1989).
• Edna B. Foa has been described as one of the leading experts in post-traumatic stress disorder research. Among her many publications, are the popular books Posttraumatic stress disorder: DSM-IV and beyond (American Psychiatric Press, Inc: 1992) and Treating the Trauma of Rape (Guilford Publications, Inc.: 1997)
• Judith Herman is a well-known psychiatrist in the field of trauma research. Her areas of research include the psychology of women, child abuse, domestic violence, and post-traumatic disorders. She is the author of the award-winning book, Trauma and Recovery (Basic Books:1991; second edition, 1997).

References

Adler, A. (1943). Neuropsychiatric complications in victims of Boston’s Coconut Grove disaster. JAMA, 123, 1098-1101.

American Psychological Association. (1994). The diagnostic and statistical manual of mental disorders, fourth edition: Text revision. Washington: APA.

Andreasen, N. J., Hartford, C. E. & Norris, A. S. (1971). Incidence of long-term psychiatric complications in severely burned adults. Ann Surg, 174, 785-793.

Andreasen, N. J. (2004). Acute and delayed posttraumatic stress disorders: A history and some issues. American Journal of Psychiatry, 161(8), 1321-1323.

Astin, M., Nishith, P. & Resick, P.A. (2000). A comparison of cognitive processing theory and prolonged exposure: A randomized controlled clinical trial. Paper presented at the World Conference of the International Society for Traumatic Stress Studies, Melbourne, Australia.

Barrowclough, C., Faragher, B., Graham, E., Pilgrim, H., Reynolds, M., Sommerfield, C. & Tarrier, N. (1999). A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic post traumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 13-18.

Black, J.L. & Keane, T.M. (1982). Implosive therapy in the treatment of combat related fears in a World War II veteran. Journal of Behavior Therapy and Experimental Psychiatry, 13, 163-165.

Brett, B. (1993). Psychoanalytic contributions to a theory of traumatic stress. In Wilson, J. P., and Raphael, B. (eds), International Handbook of Traumatic Stress Syndromes, New York: Plenum Press.

Brown, P., van der Hart, O. & van der Kolk, B. A. (1989). Pierre Janet on Post-Traumatic Stress. Journal of Traumatic Stress, 2(4), 365-378.

Burstow, B. (2005). A critique of posttraumatic stress disorder and the DSM. Journal of Humanistic Psychology, 45(4), 429-445.

Caddell, J.M., Fairbank, J.A., Keane, T.M. & Simmering, R.T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-160.

Cantor, C. (2005). Evolution and posttraumatic stress: Disorders of vigilance and defence. London: Routledge.

Clarke, K.M. (1993). Creation of meaning in incest survivors. Journal of Cognitive Psychotherapy, 7, 195-203.

Clark, D.M. & Ehlers, A. (2000). A cognitive model of posttraumatic stress disorder. Behavior Research and Theory, 38, 319-345.

Davis, K., Elliott, R. & Slatick, E. (1998). Process-experiential therapy for post-traumatic stress difficulties. In L. Greenberg, G. Lietaer, & J. Watson (Eds.), Handbook of Experiential Psychotherapy (pp. 249–271). New York: Guildford Press.

Elliott, R., Goldman, R.N., Greenberg, L.S. & Watson, J.C. (2003). Learning Emotion-Focused Therapy: The Process Experiential Approach to Change. Washington: APA.

Fairbank, J.A. & Keane, T.M. (1982). Flooding for combat-related stress disorders: Assessment of anxiety reduction across traumatic memories. Behavior Therapy, 13, 499-510.

Fecteau, G. & Nicki, R. (1999). Cognitive behavioral treatment of post traumatic stress disorder after motor vehicle accident. Behavioral and Cognitive Psychotherapy, 27, 201-214.

Friedman, M. (1997). Post traumatic stress disorder: An overview. National Center for PTSD: Dartmouth Medical School.

Greenberg, L.S. & Paivio, S.C. (1995). Resolving “unfinished business”: Efficacy of experiential therapy using empty chair dialogue. Journal of Consulting and Clinical Psychology, 63, 419-425.

Herman, J.L. (1992). Trauma and recovery. New York: Basic Books.

Kaloupec, D.G. & Keane, T.M. (1982). Imaginal flooding in the treatment of post traumatic stress disorder. Journal of Consulting and Clinical Psychology, 50, 138-140.

Kessler, R.C., Sonnega, A., Bromet, E., Hugues, M. & Nelson, C.B. (1996). Post-traumatic stress disorder in national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060.

Lerner, P. (2003). Hysterical men: War, psychiatry, and the politics of trauma in Germany, 1890-1930. Ithaca, NY: Cornell University Press.

Meichenbaum, D. (1994). A clinical handbook/practical therapist manual for assessing and treating adults with post-traumatic stress disorder (PTSD). Waterlook, Ontario, Canada: Institute Press.

Nieuwenhuis, J.A. & Paivio, S.C. (2001). Efficacy of emotion focused therapy for adult survivors of child abuse: A preliminary study. Journal of Traumatic Stress, 14, 115-134.

Ochberg, F. (1998). Post-traumatic therapy and victims of violence. New York: Brunner/Mazel.

Parry-Jones, B. and Parry-Jones, W.L.L. (1994). Posttraumatic stress disorder: supportive evidence from an eighteenth century natural disaster. Psychological Medicine, 24, 15-27.

Rosen, G. M. (Ed.). (2004). Posttraumatic stress disorder: Issues and controversies. West Sussex, England: John Wiley and Sons, Ltd.

Souliere, M. (1995). The differential effects of the empty chair dialogue and cognitive restructuring on the resolution of lingering angry feelings. (Doctoral dissertation, University of Ottawa, 1994). Dissertation Abstracts International, 56, 2342B. (University Microfilms No. AAT NN95979).

Thornett, B. (2000). Traumatic events and their aftermath. Trauma Recovery Resource Network: http://www.traumanetwork.com.

Watson, J.C. (2006). Resolving trauma in process experiential therapy. In G. Striker & J. Gold (Eds.) A Case Book in Psychotherapy Integration. Washington: APA Books.

Wilson, J. P. (1994). The historical evolution of PTSD diagnostic criteria: From Freud to DSM-IV. Journal of Traumatic Stress, 7(4), 681-698.

Relevant Websites

The Trauma Centre: http://www.traumacenter.org/

Sensorimotor Psychotherapy Institute: http://www.sensorimotorpsychotherapy.org/faculty.html

Other Sites Discussion Trauma

http://en.wikipedia.org/wiki/Post-traumatic_stress_disorder