The relationship of peritraumatic dissociation and posttraumatic stress: findings in female Vietnam theater veterans

This study examined the relationship of dissociation at the time of trauma, as assessed by the Peritraumatic Dissociation Experiences Questionnaire, Rater Version (PDEQ-RV; C.R. Marmar, D.S. Weiss, & T.J. Metzler, in press), and posttraumatic stress symptoms in a group of 77 female Vietnam theater veterans. PDEQ-RV ratings were found to be associated strongly with posttraumatic stress symptomatology, as measured by the Impact of Event Scale (M.J. Horowitz, N. Wilner, & W. Alvarez, 1979), and also positively associated with level of stress exposure and general dissociative tendencies, measured by the Dissociative Experiences Scale. The PDEQ-RV was unassociated with general psychiatric symptomatology, as assessed by the clinical scales of the Minnesota Multiphasic Personality Inventory-2 (J.N. Butcher, W.G. Dahlstrom, J.R. Graham, A. Tellegen, & B. Kaemmer, 1989). The PDEQ-RV was predictive of posttraumatic stress symptoms beyond the contributions of level of stress exposure and general dissociative tendencies. The findings provide further support for the reliability and validity of the PDEQ-RV as a measure of peritraumatic dissociation.

Characteristics of emergency services personnel related to peritraumatic dissociation during critical incident exposure

OBJECTIVE

The aim of this study was to identify characteristics of emergency services personnel related to acute dissociative responses at the time of critical incident exposure, a phenomenon designated "peritraumatic dissociation."

METHOD

The authors studied 157 rescue workers who responded to the Nimitz Freeway collapse during the 1989 Loma Prieta earthquake in the San Francisco Bay Area as well as 201 rescue workers who were not involved in that disaster. Demographics, level of critical incident exposure, perceived threat at the time of exposure, personality attributes (assessed by the Hogan Personality Inventory), coping strategies (assessed by the Ways of Coping Questionnaire), and locus of control were related to subjects' scores on the Peritraumatic Dissociative Experiences Questionnaire.

RESULTS

According to univariate tests, the subjects with clinically meaningful levels of peritraumatic dissociation were younger; reported greater exposure to critical incident stress; felt greater perceived threat; had lower scores on the adjustment, identify, ambition, and prudence scales of the Hogan Personality Inventory; had higher scores on measures of coping by means of escape-avoidance, self-control, and active problem solving; and had greater externality in locus of control. Linear modeling with multiple logistic regression analyses indicated that greater feelings of perceived threat, coping by means of escape-avoidance, and coping by means of self-control were associated with a greater likelihood of being in the peritraumatic dissociation group, above and beyond age and exposure to stress.

CONCLUSIONS

Rescue workers who are shy, inhibited, uncertain about their identity, or reluctant to take leadership roles, who have global cognitive styles, who believe their fate is determined by factors beyond their control, and who cope with critical incident trauma by emotional suppression and wishful thinking are at higher risk for acute dissociative responses to trauma and subsequent posttraumatic stress disorder.

Open trial of fluvoxamine treatment for combat-related posttraumatic stress disorder

A 10-week open-label trial of fluvoxamine was conducted for male Vietnam combat veterans with chronic PTSD. Subjects were excluded if they met full current criteria for panic disorder or agoraphobia, and lifetime criteria for psychosis, bipolar disorder, or organic mental syndrome. Repeated MANOVA was performed to determine change over time. Fluvoxamine was well tolerated; side effects were observed primarily early in treatment with headache, insomnia, sedation, and gastrointestinal distress being most frequent. Fluvoxamine was effective for treating the core intrusion, avoidance, and arousal symptoms of PTSD. Large treatment effects were seen by 4-6 weeks, and maintained at 10 weeks. The magnitude of change was greater than has been previously reported for antidepressant treatment of male Vietnam combat veterans with PTSD.

Stress responses of emergency services personnel to the Loma Prieta earthquake Interstate 880 freeway collapse and control traumatic incidents

A three-group quasi-experimental design contrasted the responses of rescue workers to the 1989 Loma Prieta earthquake Interstate 880 freeway collapse (n = 198) with responses to critical incident exposure of Bay Area Controls (n = 140) and San Diego Controls (n = 101). The three groups were strikingly similar with respect to demographics and years of emergency service. The I-880 group reported higher exposure, greater immediate threat appraisal, and more sick days. The three groups did not differ on current symptoms. For the sample as a whole EMT/Paramedics reported higher peritraumatic dissociation compared with Police. EMT/Paramedics and California road workers reported higher symptoms compared with Police and Fire personnel. Nine percent of the sample were characterized as having symptom levels typical of psychiatric outpatients. Compared with lower distress responders, those with greater distress reported greater exposure, greater peritraumatic emotional distress, greater peritraumatic dissociation, greater perceived threat, and less preparation for the critical incident.

Predicting symptomatic distress in emergency services personnel

This study identified predictors of symptomatic distress in emergency services (EMS) personnel exposed to traumatic critical incidents. A replication was performed in 2 groups: 154 EMS workers involved in the 1989 Interstate 880 freeway collapse during the San Francisco Bay area earthquake, and 213 counterparts from the Bay area and from San Diego. Evaluated predictors included exposure, social support, and psychological traits. Replicated analyses showed that levels of symptomatic distress were positively related to the degree of exposure to the critical incident. Level of adjustment was also related to symptomatic distress. After exposure, adjustment, social support, years of experience on the job, and locus of control were controlled, 2 dissociative variables remained strongly predictive of symptomatic response. The study strengthens the literature linking dissociative tendencies and experiences to distress from exposure to traumatic stressors.

Predicting symptomatic distress in emergency services personnel

This study identified predictors of symptomatic distress in emergency services (EMS) personnel exposed to traumatic critical incidents. A replication was performed in 2 groups: 154 EMS workers involved in the 1989 Interstate 880 freeway collapse during the San Francisco Bay area earthquake, and 213 counterparts from the Bay area and from San Diego. Evaluated predictors included exposure, social support, and psychological traits. Replicated analyses showed that levels of symptomatic distress were positively related to the degree of exposure to the critical incident. Level of adjustment was also related to symptomatic distress. After exposure, adjustment, social support, years of experience on the job, and locus of control were controlled, 2 dissociative variables remained strongly predictive of symptomatic response. The study strengthens the literature linking dissociative tendencies and experiences to distress from exposure to traumatic stressors.

Childhood trauma and posttraumatic stress disorder in substance abuse inpatients

This pilot study examined: the prevalence of childhood trauma in a sample of male veteran substance abuse inpatients, and the relationship of childhood trauma to substance abuse in this sample, controlling for posttraumatic stress disorder (PTSD). Forty-six subjects were interviewed using the Traumatic Antecedents Questionnaire, Structured Clinical Interview for DSM-III-R (SCID)-P Psychoactive Substance Use Disorders module, the Addiction Severity Index, and the SCID-NP-V PTSD module. Seventy-seven percent of subjects had been exposed to severe childhood trauma. Fifty-eight percent had lifetime PTSD. The total number of lifetime substance dependence disorders was strongly positively associated with total childhood trauma exposure. This relationship remained significant after controlling for demographics, family history of alcohol problems, combat exposure, and lifetime PTSD, including combat-related PTSD. A substantial number of these subjects reported exposure to childhood trauma, which in turn was related to multiple substance dependence. This has important implications for the natural history and prevention of multiple substance dependence disorders.

Lithium for irritability in post-traumatic stress disorder

Irritability is often a problem for patients with Post-Traumatic Stress Disorder (PTSD). We describe two cases that illustrate the use of lithium in the treatment of veterans with PTSD who complained of serious problems with irritability or angry outbursts. These cases are discussed in the context of evidence that lithium may be useful in other patients with disorders of impulse control. The evidence linking disorders of anger and impulse control to a dysregulation in neurotransmitter regulation, particularly in serotonergic pathways, supports a psychopharmacologic approach to treatment. These findings should lead to further study of the role of lithium in the treatment of this symptom complex in patients with PTSD.

Does trauma-linked dissociation vary across ethnic groups?

This investigation assessed the relationship between traumatic stress exposure and dissociation in male Vietnam theater veterans from three ethnic groups. Subjects were African-American (N = 61), Caucasian (N = 91), and Hispanic (N = 73) veterans who completed the Dissociative Experience Scale and a measure of war zone stress exposure, and who were rated on the Peritraumatic Dissociative Experiences Questionnaire-Rater Version. Greater exposure to war zone stress was associated with reports of more dissociation at the time of trauma and with more general dissociative experiences both when the data were pooled and when examined separately for each group. After controlling for the effects of war zone stress exposure, the significant differences found in peritraumatic and general dissociative experiences across the three ethnic groups no longer were evident. This investigation demonstrated that among American Vietnam veterans, greater exposure to traumatic stress is related to more dissociative experiences, regardless of ethnicity.

Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans

OBJECTIVE

The aim of this study was to determine the reliability and validity of a proposed measure of peritraumatic dissociation and, as part of that effort, to determine the relationship between dissociative experiences during disturbing combat trauma and the subsequent development of posttraumatic stress disorder (PTSD).

METHOD

A total of 251 male Vietnam theater veterans from the Clinical Examination Component of the National Vietnam Veterans Readjustment Study were examined to determine the relationship of war zone stress exposure, retrospective reports of dissociation during the most disturbing combat trauma events, and general dissociative tendencies with PTSD case determination.

RESULTS

The total score on the Peritraumatic Dissociation Experiences Questionnaire--Rater Version was strongly associated with level of posttraumatic stress symptoms, level of stress exposure, and general dissociative tendencies and weakly associated with general psychopathology scales from the MMPI-2. Logistic regression analyses supported the incremental value of dissociation during trauma, over and above the contributions of level of war zone stress exposure and general dissociative tendencies, in accounting for PTSD case determination.

CONCLUSIONS

These results provide support for the reliability and validity of the Peritraumatic Dissociation Experiences Questionnaire--Rater Version and for a trauma-dissociation linkage hypothesis: the greater the dissociation during traumatic stress exposure, the greater the likelihood of meeting criteria for current PTSD.

Problems in families of male Vietnam veterans with posttraumatic stress disorder

Interviews were conducted with a nationally representative sample of 1,200 male Vietnam veterans and the spouses or co-resident partners of 376 of these veterans. The veteran interview contained questions to determine the presence of posttraumatic stress disorder (PTSD) and items tapping family and marital adjustment, parenting problems, and violence. The spouse or partner (S/P) interview assessed the S/P's view of these items, as well as her view of her own mental health, drug, and alcohol problems and behavioral problems of school-aged children living at home. Compared with families of male veterans without current PTSD, families of male veterans with current PTSD showed markedly elevated levels of severe and diffuse problems in marital and family adjustment, in parenting skills, and in violent behavior. Clinical implications of these findings are discussed.

Psychodynamic group treatment of posttraumatic stress disorder in Vietnam veterans

Exposure to combat frequently imparts a sense of aloneness, guilt, and helplessness. These and other intrapsychic and interpersonal issues need to be addressed in treating Vietnam veterans suffering from posttraumatic stress disorder (PTSD). Group therapy is proposed as a core treatment modality for dealing with these problems. A model is proposed in which patients are treated for 1 year or more in weekly groups that meet for 16-week sequential segments. Clinical guidelines are made explicit to new members by the co-therapists. Discussion topics deal not only with traumatic experiences related to combat, but also with important pre- and postwar issues that are relevant to the symptoms of PTSD. Timely integration and working through of these issues in the group is critical.

Problems in families of male Vietnam veterans with posttraumatic stress disorder

Interviews were conducted with a nationally representative sample of 1,200 male Vietnam veterans and the spouses or co-resident partners of 376 of these veterans. The veteran interview contained questions to determine the presence of posttraumatic stress disorder (PTSD) and items tapping family and marital adjustment, parenting problems, and violence. The spouse or partner (S/P) interview assessed the S/P's view of these items, as well as her view of her own mental health, drug, and alcohol problems and behavioral problems of school-aged children living at home. Compared with families of male veterans without current PTSD, families of male veterans with current PTSD showed markedly elevated levels of severe and diffuse problems in marital and family adjustment, in parenting skills, and in violent behavior. Clinical implications of these findings are discussed.

Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls

To determine if Vietnam theater veterans were more likely than controls to have a specific psychiatric disorder other than posttraumatic stress disorder, the rates of specific psychiatric disorders were estimated using the Diagnostic Interview Schedule for national samples of veterans who served in Vietnam, other veterans of the Vietnam era, and matched civilian controls. Overall, there were few differences in rates of disorder between theater and other veterans; there were somewhat more differences between theater veterans and civilians. There were striking differences, however, in rates for most disorders, both lifetime and current, between male theater veterans with high levels of exposure to war zone stress and other male veterans or civilians. Female veterans exposed to high levels of war zone stress also had higher rates than other female respondents for several disorders.

Psychotherapy process research: progress, dilemmas, and future directions

The first several decades of psychotherapy process research have produced advances in measure development and substantive findings of process-outcome relations. A recent paradigm shift toward sequentially patterned, significant change episodes is described, emphasizing segmentation of process by meaningful patterns wherever they occur. Theoretical, psychometric, and data analytic dilemma are reviewed. Strategies are offered that may enhance future research efforts. These include greater attention to construct validity of measures, the relation of process to phase-specific outcome criteria, and the continuing development of multivariate data analytic strategies that take into account Patient X Treatment interactions as well as the sequential dependency of process data. The development of a national archive of significant change events is recommended to advance modeling of the change process, segmentation, construct validation of measures, integration of qualitative and quantitative approaches, and development of a cross-theoretical language for therapy process.

Psychotherapy process research: Progress, dilemmas, and future directions

The first several decades of psychotherapy process research have produced advances in measure development and substantive findings of process-outcome relations. A recent paradigm shift toward sequentially patterned, significant change episodes is described, emphasizing segmentation of process by meaningful patterns wherever they occur. Theoretical, psychometric, and data analytic dilemma are reviewed. Strategies are offered that may enhance future research efforts. These include greater attention to construct validity of measures, the relation of process to phase-specific outcome criteria, and the continuing development of multivariate data analytic strategies that take into account Patient X Treatment interactions as well as the sequential dependency of process data. The development of a national archive of significant change events is recommended to advance modeling of the change process, segmentation, construct validation of measures, integration of qualitative and quantitative approaches, and development of a cross-theoretical language for therapy process.

Alliance and outcome in late-life depression

Older adults who met criteria for major depressive disorder were randomly assigned to behavioral, cognitive, or brief dynamic therapy. Symptoms were equally reduced across the three treatment conditions. Early in treatment, alliance ratings were obtained from both therapists and patients and were related to outcome. We calculated one therapist alliance composite score and five patient alliance factor scores. In general, no agreement was found between therapists' and patients' judgments of alliance. Levels of alliance were found to be not significantly different across the three treatment conditions. For the sample as a whole, only the patient factor of Patient Commitment was found to be associated with depressive symptoms after treatment, with the strongest findings in the cognitive therapy condition. The Patient Commitment factor uniquely contributed to outcome over and above the contribution of initial symptomatology and symptomatic change at midpoint in therapy. Expected trends of association with outcome were observed for the therapist alliance composite score in brief dynamic therapy and for the patient factor of Patient Working Capacity in both cognitive and brief dynamic therapy. Findings are discussed in terms of their theoretical and clinical implications.

A controlled trial of brief psychotherapy and mutual-help group treatment of conjugal bereavement

Sixty-one women who sought treatment for unresolved grief reactions 4 months to 3 years after the death of their husbands were randomly assigned to either brief dynamic psychotherapy with experienced clinicians or mutual-help group treatment led by nonclinicians. Women in both groups experienced a reduction in stress-specific and general symptoms as well as improvement in social and work functioning. Women in the brief psychotherapy group showed a greater decline in one measure of general symptoms, and there was greater attrition in the group treatment condition. When two subgroups who had completed the majority of sessions were compared, treatments were found to be equally effective.