Interview:

Better Understanding, Better Recognition

Terence M. Keane, Ph.D., heads the division of behavioral sciences at the National Center for PTSD in Boston. The division is at the forefront of efforts to develop scientifically validated measures and treatments for PTSD. Current investigations address both psychological and psychophysiological assessment procedures. In addition, division staff conduct research on basic mechanisms of PTSD related to cognitive information processing, family and social support factors and gender issues

Q. How did PTSD become a commonly recognized disorder?

A. A lot of the growth in understanding has occurred over the past 20 years. Violence against women and the resulting traumatic effects became an issue in the public forum. This was coupled with an interest in the aftermath of the Vietnam war, when the veterans really wouldn't take no for an answer. They were very interested in having their issues and their problems addressed by the professional communities. Those two things collided and that was synergy for the development of the PTSD diagnosis in the mid-'70s.

Once it was understood that PTSD was a syndrome, in 1980, people realized it applied to a variety of major life and death situations, such as automobile accidents, aborted airplane takeoffs, earthquakes and natural disasters, floods and that sort of thing.

Q. Did this increased understanding lead to changes in how patients were treated for the disorder?

A. It set the stage for the development of treatments that were geared specifically for the trauma symptomology. So many treatments these days are geared toward the specific symptoms of a disorder that having a particular diagnosis made it a much more successful enterprise to identify and treat PTSD. It also made it possible to tailor many of the behavioral and cognitive-behavioral treatments.(6)

Q. Are there psychological symptoms that make PTSD stand out from other conditions such as depression and anxiety?

A. The biggest ones are the reliving and the preoccupation with the traumatic event. There are also the avoidance features in which people try to push the memories out of their minds. People say, "I spend a lot of time trying to forget it." But, of course, that doesn't really work.

Q. Is it possible to characterize differences in the way men and women experience traumatic events and develop PTSD?

A. There are gender differences in responding to traumatic events, and the exposures are also different. But there is no simple answer. At least in some of the studies that we have done, women were more likely to be exposed to traumatic experiences in childhood.(1) So, even though men are more commonly exposed to military-related traumas, which dramatically increase the risk of developing PTSD, women are more likely to be exposed to sexual traumas. Overall, men are exposed to more traumatic life events and women are more likely to develop PTSD once exposed. However, women are more likely to use their social support systems than men are, and that may work in their favor.

Q. Can you explain the role memory plays in PTSD?

A. People in a life-threatening situation are unlikely to pay attention to anything else that is going on around them. People recall the central features of the experience, but few of the peripheral details. The fragmented memory that so many of these victims talk about may be due to the fact that they have forgotten major chunks of it; they remember the fundamental pieces of what happened but forget the other parts of the memory. Or another possibility is that they never consolidated it in memory in the first place. There is another school of thought about this, which is that people may successfully push these traumatic memories out of their minds, but there is only limited evidence for this experimentally.

Q. Are some people more likely to develop PTSD than others?

A. Women are more likely to develop PTSD.(1) African-Americans, when they are exposed to trauma, are more likely to develop PTSD. People who are exposed to the most intense trauma are the most likely to develop PTSD. The higher degree of exposure to trauma the more likely you are to develop PTSD. So, if you have something that happens to you more than once, or you have something that occurs to you over a very long period of time, the likelihood of developing PTSD is increased.

Q. Has combat trauma defined PTSD?

A. It certainly has had a lot to do with it but I don't think that it has been the sole basis for defining PTSD. All of the committees that I have served on, for example, have always included people who have worked with other populations. We have accumulated increased knowledge in the past decade about traumatic events that are non military. It is safe to say that much of what we know about traumatic events had their origins in the study of military trauma, but has been confirmed across multiple types of traumatic events.

Q. Is it true that some heart attack patients develop PTSD? Is that an important area of research?

A. There have been a few studies of people with PTSD following myocardial infarction. Prevalence rates of PTSD are about 10 percent, which may seem relatively small until you take into account the millions of people worldwide who have a heart attack each year. Cancer is another disease that PTSD researchers have been examining, particularly with some of the people who have really noxious treatments, such as bone marrow transplant. Maybe 15 percent to 20 percent of them develop PTSD.

Q. Refugees present a unique case. How does PTSD differ among these people compared with other cases of the disorder?

A. Refugees tend to have more intense symptoms and it takes them longer to recover from these symptoms. Part of this is also due to the fact that refugees often go years without treatment. So many of the refugees that we are treating in the Balkans are people who were in the various wars, which were five to 10 years ago. The five or more years it takes for these patients to get to America where they can get help often makes it harder for them to recover.

Q. Are there forms of PTSD-causing trauma that might not be commonly expected?

A. One of the areas that is interesting is the number of mothers who develop PTSD following deliveries that are unusually difficult. There has also been a long-standing recognition of PTSD caused by awareness during surgery, when patients are partially conscious despite general anesthesia. There are some very interesting data to suggest that it's more common than we previously thought.

Q. With increased understanding of PTSD, will it become more commonly diagnosed within the primary care setting?

A. I think it's already happening, actually. There is a lot of interest in it because so many of the primary care doctors know that their patients have been targets of violence in the home and the community and so they're really very much tuned into it, which I think is great.

Q. Are there good tools for these doctors to use to identify PTSD?

A. I don't know that there are so many yet, although there are lots of research groups working on them. But there is no single gold standard, either for measuring trauma exposure or trauma symptomatology.

Q. Exposure therapy, a form of cognitive behavioral therapy, is the recommended treatment for PTSD. How do you describe it?

A. Exposure therapy consists of gradually and systematically trying to help individuals to process the memories or the cues associated with the trauma experiences. It involves slow and sustained presentation of the trauma memory from start to ending in systematic, successive ways until there is a reduction in the reactivity to those memories. It shares in common some of the old maxim: if you fall off a horse you need to get back on it. One needs to consciously go through it again in your mind multiple times in the presence of an psychological expert. Otherwise, you just keep repeating it again and again in your own mind without the psychologist to give you cues about what to do next.

Q. PTSD often presents in association with other psychiatric disorders such as depression and anxiety. Is it best to treat these conditions simultaneously or sequentially?

A. That is the $64,000 question that nobody has really answered yet. We do know that a lot of people who are treated successfully for PTSD usually with exposure therapy or other forms of cognitive behavior therapy also experience reductions in their depression, for example.(7) That's really the only thing that has been measured systematically or carefully. But that's very good news.

A Burgeoning Field of Research

Medical records for combat veterans suggest that symptoms of post-traumatic stress disorder go back more than 100 years, but PTSD was officially recognized as a distinct cluster of symptoms only about 20 years ago.

"For 140 years or so, the lion's share of the work, both clinical and conceptual, has been on military veterans, starting with the American Civil War and the Franco-Prussian War. What's interesting is that after each major war, the symptoms are rediscovered, get a different name and then are forgotten until the next war," notes Matthew J. Friedman, M.D., Ph.D., executive director of the National Center for Post-Traumatic Stress Disorder.

The National Center for PTSD is a seven-site consortium created 12 years ago at the behest of Congress to educate the public and consolidate research funding on PTSD project.

"When it finally became official, in 1980, PTSD was a diagnosis waiting to happen," says Friedman, reciting a laundry list of research areas currently being explored including epidemiology, psychobiology, information processing, behavioral manifestation, psychophysiology and, of course, both pharmacological and cognitive behavioral therapies.

"The news is quite favorable even compared with five years ago," according to Paula P. Schnurr, Ph.D., Friedman's deputy at the National Center. "There are treatments for this disorder."

Exposure therapy, which is a type of cognitive behavioral therapy, is the most effective treatment for PTSD. Selective serotonin reuptake inhibitors, modern antidepressants, are also recommended for PTSD patients.(13) But there are no drugs that have been specifically developed for the disorder. However, new drugs are in the works that directly target the biological changes that occur in PTSD.

With official recognition and an expanding field of experts interested in studying PTSD, the ISTSS was formed. "It became clear several years ago that there was certainly an interest in getting people together to share their experiences and support each other through their very difficult clinical work with trauma survivors," says Rachel Yehuda, M.D., Ph.D., who has served as vice president of the society. ISTSS was founded in 1985 and is dedicated to the discovery and dissemination of knowledge that seeks to reduce people's exposure to traumatic experiences and their immediate and long-term consequences.

The Society provides a forum for sharing research findings, clinical strategies, public policy concerns and theoretical formulations concerning trauma in the United States and around the world. Members of ISTSS include psychiatrists, psychologists, social workers, nurses, counselors, researchers, administrators, advocates, journalists, clergy and others with an interest in the study and treatment of traumatic stress.

The Society also recently formed the National Trauma Foundation to get more consumer input. "We have been doing a lot of consumer-oriented activities," says Yehuda, including participation in the PTSD Alliance, a group of professional and advocacy organizations that have joined to provide educational resources to the public and professionals.

Interview #2: : Discovering the Biology of Fear

Rachel Yehuda, Ph.D., is director of the posttraumatic stress disorder program at the Bronx Veterans Administration Medical Center and professor of psychiatry at Mount Sinai School of Medicine. Dr. Yehuda has written more than 150 book chapters and journal articles and has co-authored or edited six books. She is founder and director of the Specialized Treatment Program for Holocaust Survivors and their Families and has served as vice president of the International Society for Traumatic Stress Studies.

Q. What has led to the current understanding of the physiological changes that occur in patients with PTSD?

A. Our work started about 10 or 12 years ago, and at the time very little was known about the biology of PTSD. I entered this field with a basic-science background and had been doing work on the biology of stress in laboratory rats, examining such questions as what are the brain processes that control the stress response. We began studies to look at the stress hormone cortisol in people with PTSD, which was an obvious thing to do because cortisol had been found to be increased in major depression and PTSD looks very much like major depression from a clinical perspective. Additionally, increased cortisol levels have been associated with acute and chronic stress. But when we initially did the studies on Vietnam veterans we were very surprised to learn that, contrary to our expectations, cortisol levels were not higher in Vietnam veterans, but rather lower.(8) For the past 15 years or so, we have been trying to follow up on this very intriguing observation of low cortisol in PTSD.

Q. What have the past 15 years of research revealed?

A. When we started our studies, our hypothesis was that we were going to be looking at a prolonged, but essentially, normal stress response and would observe alterations consistent with the biology of stress. As we were obtaining paradoxical results in the laboratory, people who were doing epidemiological studies were also coming up with unexpected findings. These findings were first that contrary to the expectation that traumatic events were rare, they were quite prevalent in society, and second, PTSD only occurred in a proportion of those exposed.(1) The convergence of the two findings, the biologic findings and the prevalence findings, suggested to us that we were possibly looking at something that is a type of response to trauma but not necessarily a universal response to trauma. The biologic findings in PTSD then could be examined in a different light, because when we put them together with the epidemiological findings we were faced with a new set of questions: does PTSD represent a failure of the normal stress response, and if so, what are the risk factors for this, and how is it reversed.

Q. What did you find?

A. Our first step was to examine a wide range of trauma survivors. Our studies began in Vietnam veterans, but we soon started to study Holocaust survivors and then veterans of other wars, women who had been exposed to trauma either in adulthood or early childhood and now we're also examining children. And so we have been able to take quite a broad perspective of the biology of PTSD by looking at many individual differences including the type of trauma exposure, the age that a person was first exposed to trauma, the duration of symptoms, gender and all sorts of things like that.

Q. Was this approach revealing?

A. Study in those groups helped us understand that low cortisol is present in many persons with PTSD. One idea we have had is that cortisol may be low in PTSD because it may have also been low before the person was exposed to trauma.(9) We're not sure about this. However, there are recent data that are quite compelling. They show that if anything, trauma survivors who go onto develop PTSD, or who are at greater risk for PTSD, are likely to show lower cortisol levels in the acute aftermath of a traumatic event compared with those who do not develop PTSD. There seems to be an attenuated cortisol response in these people.(10,11)

Q. How would this affect someone during or after a traumatic event?

A. We don't know for sure. However, we can take a few guesses about how this might affect people by reflecting on the biology of fear. When people are afraid, the body activates several reactions that are designed for a 'fight-or-flight' response. One of these reactions is the release of adrenaline, which is responsible for increasing blood pressure and heart rate and increasing glucose to muscles. This is so people can respond to an immediate danger. Once the immediate danger is no longer present, the body begins a process of shutting down the stress response and this process involves the release of cortisol. And if you didn't have enough cortisol at the time of the trauma, then one of the effects of that might be that you can't turn off the stress response or that you might come to feel as if you are continuing to experience the adrenaline response. Consistent with this is the observation that trauma survivors with PTSD often have higher levels of catecholamines, stimulating hormones like adrenaline, under both normal resting conditions and in response to being reminded of their trauma.

Q. How do these biological changes affect the PTSD patient's experience and memory?

A. Basically what makes PTSD such a disabling condition is that when PTSD patients remember the traumatic event, they don't just have an image of what happened, but they also recall the physiologic response they had of fear, helplessness or horror. They may even actually experience components of that physiologic response as they are remembering the event long after it has occurred. So remembering the event becomes a traumatic experience itself for somebody with PTSD.

Q. In relation to the traumatic event, when does the physiologic response occur?

A. There are some physical changes that are observable very soon after the trauma and some of those changes persist and some of those go away, such as increased heart rate. And at about one month, there seems to be the development of some new biologic changes, such as the development of an altered auditory response to startling stimuli. Therefore, there seems to be a cascade, in which earlier alterations may turn on later ones. This suggests the right kinds of early intervention may be quite important.

Q. Is there a difference between regular PTSD and the delayed form of the disorder?

A. Most people do not have delayed PTSD, but it certainly can occur. And particularly what is possible is for people to develop delayed PTSD in response to subsequent events. For example, we have a lot of World War II veterans who really didn't express PTSD symptoms for most of their lives, but then they have an emotional experience that reactivates their memories, such as they retire or lose a loved one or they saw war scenes on live TV news. They can then develop symptoms for the first time.(12)

Q. Why does this happen?

A. If you think about trauma as changing the biologic system and think about PTSD as being a response not only to the current event but a history of events then it very may well be that the first exposure does not induce PTSD but that subsequent exposure will. There seems to be a cumulative or sensitization effect, because every time we experience something this is information that changes the brain.

Q. Are the physiological characteristics of PTSD uniform across different types of trauma?

A. Yes and no. There are changes that are associated with different traumas, but my hypothesis is that they are probably associated with different individuals' characteristics more than just the type of trauma. For example, if I told you hypothetically that cortisol levels are different in older veterans versus younger veterans, this might be a statement about the fact that the Gulf War was different from the Korean War but may also be a statement about the fact that Gulf War Veterans are much younger.

Q. What other types of physiological changes are associated with PTSD?

A. We see changes in immune profiles, brain metabolism and psychophysiological responses such as memory and cognitive performance. But at this time, we don't know what the prime mover is - what alterations are a consequence of the trauma, and which are consequence of other biologic changes.

Q. Why do you think people don't seek treatment after experiencing trauma?

A. It depends on what has happened to you. There are certain events that are associated with a very high degree of shame and guilt. That includes things like rape, incest and generally being victimized in a way that makes you feel helpless. People feel very self-conscious when that happens; they feel guilty and ashamed.

People who have car accidents or are exposed to natural disasters are often so busy cleaning up after the impact of those events that they don't tend to their mental health needs right away. Although those types of trauma are not really associated with shame or guilt, somebody who has just lost her home is not likely going to see a psychologist the next morning.

With other kinds of traumatic events, people may hope and pray that if they stop thinking about it somehow they'll be fine. People feel that they should be able to "get over it" and I think that is what other people tell them.

Q. How does this behavior affect the progress and treatment of PTSD?

A. What basically happens is that things cascade. Other secondary problems develop and after awhile it's very hard to be sure when problems began or whether it was in fact the traumatic event that initiated the problems. It is also easy for people to think their problems are due to events that happened to them earlier (before the trauma) or maybe it's just them - that is a flaw in their character that leads to psychological problems.

Unless the symptoms are really, very strikingly, the symptoms associated with trauma memories, then it will be hard for somebody to really make that connection between not being able to sleep or concentrate, or being irritable, and a traumatic event, particularly if the person was able to function relatively normally for a short period of time after the event or even a long period of time.

I think that the most important thing is to be aware that traumatic events can be very psychologically disabling and so it is important to tend to oneself in the immediate aftermath of the event. People should also be aware that by the time you get three, four, five years away from the event, it's going to be very hard to convince themselves that they're still experiencing the effects of that event.

Q. Can these people expect to fully recover from their experience and this disorder?

A. Yes. Many people - in fact most - get better following traumatic experiences. Our group has worked a lot with Holocaust survivors and combat veterans who were exposed to very chronic and horrible experiences, and recovery is a very tough agenda. For people who have experienced what we call a single-episode traumatic event, there is a very good chance that they will fully recover. In fact, some of our veterans have responded to this September 11th tragedy by indicating that they wish they would have had the support from the community that the victims and survivors are receiving; many believe they would have been able to overcome their symptoms much sooner.

The Traumatic Stress Effects of Terrorism: National Center for Post-Traumatic Stress Disorder, Department of Veteran Affairs

Terrorism erodes a sense of security and safety at both the individual and community level. It can challenge the natural need of humans for the world to be predictable, orderly and controllable. Studies have shown that deliberate violence creates longer lasting mental health effects than natural disasters or accidents. The consequences both for individuals and the community are prolonged, and survivors often feel that an injustice has been done to them. This can lead to anger, frustration, helplessness, fear and a desire for revenge. Studies have shown that acting on this anger and need for revenge can increase feelings of anger, guilt, and distress, rather than decreasing them.

However, the mechanisms of natural recovery from traumatic events are strong. Many trauma experts agree that the psychological outcome of our community as a whole will be resilience, not psychopathology. For most, fear, anxiety, re-experiencing, urges to avoid, and hyperarousal symptoms, if present, will gradually decrease over time.

Research has shown that those who are most at risk for more severe traumatic stress reactions such as PTSD are those who have experienced the greatest magnitude of exposure to the traumatic event, such as victims and their families.(14)

In this incident, many surviving rescue workers will also have direct relationships, or indirect exposure to those who are missing or killed, and will therefore be coping with their own losses as well as with the demands of the rescue mission. A particularly difficult task for these rescue workers will be the removal of the casualties and other aspects of body identification and removal, which have been shown to be particularly traumatic and associated with higher rates of PTSD.

Fortunately, there have been very few terrorist attacks in the United States. One implication, however, is that there is little known about how people are affected by terrorism. A consistent finding is that, while most individuals exhibit resilience over time, people most directly exposed to terrorist attacks are at a higher risk to develop PTSD. Problems with anxiety and depression are also commonly reported.(15, 16)

Select groups that had significant problems with alcohol before the disaster are likely to have problems with alcohol use after the disaster, but new alcohol problems are rare.(17) Predictors of PTSD include being closer to the attacks, being injured and knowing someone who was killed or injured. Those who watch more media coverage are also at higher risk for PTSD and associated problems.(18,19)

For more information on the signs of and coping with PTSD, please refer to the National Center for PTSD web site at www.ncptsd.org, the International Society for Traumatic Stress Studies web site at www.istss.org and for information on helping children understand traumatic events, the National Center for Children Exposed to Violence at www.nccev.org.

The Research

1. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048-1060.

2. Schnurr, P.P., & Friedman, J.J., (1997) An overview of research findings on the nature of posttraumatic stress disorder. In Session: Psychotherapy In Practice, 3(4), 11-25.

3. Kulka, R.A., Schlenger, W.E., Fairbanks, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., & Weiss, D.S. (1990). Tauma and the Vietnam War generation: Report of findings from the National Vietnam Readjustment Study. New York: Bruneer/Mazel.

4. White, P., & Faustman, W. (1989). Coexisting physical conditions among inpatients with post-traumatic stress disorder. Military Medicine, 154(2), 66-71.

5. Schnurr, P.P., & Jankowski, M.K. (1999). Physical health and post-traumatic stress disorder: review and synthesis. Seminars in Clinical Neuropsychiatry, 4(4), 295-304.

6. Keane, T.M., & Barlow, D.H. (2001) Posttraumatic Stress Disorder, in D.H. Barlow (Ed.) Anxiety and its disorders. New York: Guilford Press.

7. Foa, E.B. & Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York, N.Y.: Guilford Press.

8. Mason, J.W., Giller, E.L., Kosten, T.R., Ostroff, R.B., & Podd, L. (1986). Urinary free-cortisol levels in posttraumatic stress disorder patients. Journal of Nervous and Mental Disease, 174(3), 145-149.

9. Yehuda, R., Halligan, S., & Grossman, R. (2001). Childhood trauma and risk for PTSD: Relationship to intergenerational effects of trauma, parental PTSD and cortisol excretion. Stress and Development, 13, 731-751.

10. Resnick, H.S., Yehuda, R., Pitman, R.K., & Foy, D.W. (1995). Effect of previous trauma on acute plasma cortisol level following rape. American Journal of Psychiatry, 152(11), 1675-1677.

11. Yehuda, R., McFarlane, A.C., & Shalev, A.Y. (1998). Predicting the development of posttraumatic stress disorder from the acute response to a traumatic event. Biological Psychiatry, 44(12), 1305-1313.

12. Port, C.L., Engdahl, B., & Frazier, P. (2001). A longitudinal and retrospective study of PTSD among older prisoners of war. American Journal of Psychiatry, 158(9), 1474-1479.

13. Ballenger, J.C., Davidson, J.R., Lecrubier, Y., Nutt, D.J., Foa, E.B., Kessler, R.C., McFarlane, A.C., & Shalev, A.Y. (2000) Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry, 61 (Suppl. 5), 60-66.

14. North, C., Nixon, S., Shariat, S., Mallonee, S., McMillen, J., Spitzanagel, E., & Smith, E. (1999). Psychiatric disorders among survivors of the Oklahoma City bombing. Journal of the American Medical Association, 282, 755-762.

15. DiGiovanni, C. (1999). Domestic terrorism with chemical or biological agents: psychiatric aspects. American Journal of Psychiatry, 156, 1500-1505.

16. Shariat, S., Mallonee, S., Kruger, E., Farmer, K., & North, C. (1999). A prospective study of long-term health outcomes among Oklahoma City bombing survivors. Journal of the oklahoma State Medical Association, 92, 178-186.

17. Smith, D., Christiansen, E., Vincent, R., & Hann, N. (1999). Population effects of the bombing of Oklahom City. Journal of the Oklahoma State Medical Association, 92, 193-198.

18. Pfefferbaum, B., Nixon, S., Tucker, P., Tivis, R., Moore, V., Gurwitch, R., Pynoos, R., & Geis, H. (1999). Posttraumatic stress responses in bereaved children after the Oklahoma City bombing. Journal of the American Academy og Child and Adolescent Psychiatry, 38, 1372-1379.

19. Pfefferbaum, B., Gurwitch, R., McDonald, N., Leftwih, M.,Sconzo, G., Messenbaugh, A., & Schultz, R. (2000). Posttraumatic stress among children after the death of a friend or acquaintance in a terrorist bombing. Psychiatric Services, 51, 386-388.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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