Whiplash neck injury

Whiplash, or post-traumatic, neck injury is an increasingly frequent clinical problem. Large numbers of patients present with both acute and chronic physical symptoms. It has frequently been alleged that psychological factors and social variables (especially the influence of possible compensation) are major causes of persistent physical complaints and disability. There have been few methodologically satisfactory studies, and very little attention has been paid to mental state and quality of life issues. Epidemiology, clinical features, prognosis, and aetiology are all reviewed with a special emphasis on psychological outcome and variables. It is argued that such factors are as important in relation to whiplash injuries as are other physical conditions, especially musculoskeletal disorders. In addition, specific posttraumatic symptoms are common but usually unrecognized.

A critical review of recovered memories in psychotherapy: Part II--Trauma and therapy

OBJECTIVE

The clinical implications of the use of recovered memories in psychotherapy will be examined.

METHOD

The paper will review the relationship of trauma to psychopathology and discuss how traumatic histories might be dealt with in therapy.

RESULTS

Trauma is a risk factor for psychopathology, but is only one of many etiological factors in mental disorders. The search for recovered memories in psychotherapy could present dangers for patients.

CONCLUSIONS

The most reliable memories of trauma are those that have been present throughout the patient's life.

The spectrum of emotional distress and personality changes after minor head injury incurred in a motor vehicle accident

This is a systematic presentation of the emotional and personality disorders of 33 patients who incurred minor traumatic brain injury (MTBI) in a vehicular accident. A wide spectrum of disorders was observed: cerebral personality disorder, persistent altered consciousness, post-traumatic stress, psychodynamic reactions to impairment, and complex reactions expressing neurological, somatic, and psychological dysfunctions (sexuality and somatization). Examples of each category are offered to aid identification. A total of 31/33 patients suffered an additional psychiatric disorder. Unreported head trauma and loss of consciousness (LOC) elicited by detailed interviews helped to explain the extent of impairment. Emotional disorders, added to persistent cognitive loss and other neuropsychological symptoms, greatly impair the capacity to adapt after traumatic brain injury (TBI). Clinical procedures (interview; Rorschach; observation; figure drawings; checklists) are recommended to obtain detailed personality information needed for diagnosis, prognosis, and treatment. Behavioural outcome after TBI reflects disturbance in the processing of internal and external stimulation, and disturbance of pre-existing physiological and psychological processes. Emotional distress consistent with the accident and impairment adds to the credibility of patient complaints. There is an interaction between lesion effects and various emotional disturbances, which impacts employment, social relationships, and the enjoyment of life. Prompt and sympathetic treatment will contribute to more effective treatment, and may be anticipated to reduce or prevent some persistent symptoms after minor head injury.

[Torture-related injuries--a medical challenge. Diagnosis and treatment of Falanga victims]

Torture victims are generally reluctant to present complaints linked to the torture. Many patients from refugee populations have experienced traumatic events such as war, violence and torture. Health professionals need to know more about the nature of these traumas, and how to diagnose the sequelae of torture. If they are to give torture victims adequate treatment they need to be familiar with the relevant diagnostic procedures, and how to treat health problems caused by systematic violence. A clinical case history is used to present the method of torture called Falanga, the beating of the soles of the feet. The case shows how the diagnosis and treatment of the physical injuries have a marked effect on the rehabilitation process. After receiving treatment for his foot injuries, patient's physical and mental health both improved dramatically, as did his psychosocial rehabilitation.

Subjective versus objective sleep in Vietnam combat veterans hospitalized for PTSD

Twenty-five Vietnam combat veterans with chronic severe posttraumatic stress disorder (PTSD) completed a sleep self-report questionnaire on admission to an inpatient treatment program. Between 1 and 2 months later each spent 3 or more nights in the sleep laboratory. When self-report and laboratory findings were compared, significant relationships were observed between sleep schedule items such as time-to-bed/time-out-of-bed and polysomnographic measures of sleep. In contrast, global ratings of sleep quality were generally unrelated to polysomnographic measures. These findings may have implications for survey research assessing sleep quality in traumatized populations.

Group cognitive-behavioral therapy for women with PTSD and substance use disorder

This paper describes a model of group cognitive-behavioral therapy (CBT) for women with posttraumatic stress disorder (PTSD) and substance use disorder (SUD). The need for specialized treatment derives from the high incidence of these comorbid disorders among women as well as from their particular clinical presentation and treatment needs. The treatment educates patients about the two disorders, promotes self-control skills to manage overwhelming affects, teaches functional behaviors that may have deteriorated as a result of the disorders, and provides relapse prevention training. The program draws on educational principles to make it accessible for this population: visual aids, education for the patient role, teaching for generalization, emphasis on structured treatment, testing of acquired knowledge of CBT, affectively engaging themes and materials, and memory enhancement devices.

Medium-term course of disaster victims. A naturalistic follow-up

BACKGROUND

Our aim was to describe the medium-term course (2-3 years) in a series of victims who had experienced severe trauma.

METHOD

We selected a consecutive series of 31 trauma victims and applied a structured clinical schedule (CAPS-2) to their psychiatric evaluations prepared for the court on two separate occasions approximately one year apart.

RESULTS

Post-traumatic stress disorder and depression were the commonest diagnoses, occurring in 39% and 16% of the victims respectively when they were first assessed. Most had improved between the assessments and this was especially the case for the re-experiencing of the trauma and over-arousal, but less so for avoidance; 20% of subjects showed no improvement, often being handicapped by secondary psychiatric illness.

CONCLUSION

Traumatised victims generally showed recovery in the 2-3 years after the trauma, but this was slow and was not universal.

Treatment of coexisting substance dependence and posttramatic stress disorder

This paper describes the treatment of a physician who developed posttraumatic stress disorder (PTSD) and a polysubstance use disorder after he was shot and held hostage by a patient. Inpatient treatment combined pharmacological and behavioral approaches, including systematic re-exposure via talking about the event in therapy groups. Standard methods for achieving and maintaining abstinence were used, such as asking for and accepting peer support and discussing painful feelings. Cognitive aspects of treatment included education about interactions between the two conditions. After 12 weeks the physician was free of symptoms and had minimal anxiety when exposed to salient cues of the traumatic event.

Identifying anxiety disorders in adolescents hospitalized for alcohol abuse or dependence

In structured clinical interviews of 43 adolescents hospitalized for alcohol abuse or dependence, 17 subjects met criteria for an anxiety disorder, with social phobia (N = 9) and posttraumatic stress disorder (N = 7) most common. Of these 17 subjects, only four were identified in hospital records as having an anxiety disorder. In a comparison of 30 hospitalized adolescents with a matched control group of 30 adolescents from the community, the hospitalized adolescents had a higher rate of anxiety disorders, psychoactive substance use disorders, disruptive behavior disorders, and mood disorders.

[Psychological management and after-care of severely burned patients]

Skin damage resulting from severe burn injuries is often widespread and quite deep. In addition to the organ lesion, there is also psychological damage. Subsequent scar stigmatisation and reduced function, for example of the hands, neck and the facial area, and amputations lead in individual cases not only to increased stress at work, but to significant physical, emotional and social stress as well. In some cases, this results in drastic changes of lifestyle, even resulting in severe post-traumatic stress reactions. Psychological treatment begins as early as the intensive care period, at a time when the patient is trained to be off the respirator, or when the patient is fully awake, during preparation for the transfer to the normal or "aftercare unit", as well as the time when the patient leaves the hospital. Treatment is understood primarily as "crisis interventions"--and proceeds in accordance with everybody involved in therapy, including the consultant psychiatrist, the physiotherapist, the occupational therapist, the clergyman and the social worker. The aim of psychological treatment is to offer a patient specific help in his/her current situation and is a part of the whole multi-disciplinary rehabilitation concept. Additionally, it is also intended to prevent severe short- and long-term post-traumatic stress syndromes. Thermic accidents at work or at home, including suicide attempts, in most cases involve patients who are already suffering from psychoses or neurotic personality disorders, patients with high alcohol intake, medication and drugs abuse, or conflict situation in their social and working environments (burn prone personality).(ABSTRACT TRUNCATED AT 250 WORDS)

PTSD substance abuse comorbidity and treatment utilization

The present study investigates the prevalence of posttraumatic stress disorder (PTSD) among a sample of treatment-seeking substance abusers and examines the relationship between PTSD comorbidity and rates of inpatient substance abuse treatment. Eighty-four patients (48 male and 36 female) admitted for detoxification at a private hospital were administered self-report measures of lifetime stressor events, PTSD symptomatology, and prior treatment history. Approximately one quarter of the sample was found to present with significant PTSD symptomatology. Women were more likely than men to have been physically and sexually abused, and women reported experiencing a greater number of traumatic events. Consequently, more women than men were classified as having possible PTSD. With respect to inpatient substance abuse treatment admission rates, the PTSD group reported a greater number of hospitalizations than their non-PTSD counterparts. Implications of these findings for routine trauma screening and more effective treatment for substance abusers with concomitant PTSD are highlighted.

Psychosocial consequences of traffic accidents: a two year follow-up

The aim of the study was to assess long term outcome of injuries from traffic accidents with focus on psychosocial aspects. Eighty-four persons injured in traffic accidents and with moderate to severe injuries (ISS > or = 9) were interviewed approximately two years after the accident. We examined psychosocial consequences within eight different domains; sequelae of the injury, psychological consequences, sickness compensation received, living conditions, need of assistance, working capacity, economic situation and leisure time activity. Sixty-eight percent of the persons reported that they still suffered from physical seqelae and 57% had been or were still suffering from psychological distress after the accident. Sixty-three percent were on the sick-list for at least three months because of the accident. Fifty-eight percent needed some type of handicap aid during some time after the accident. For 29% of the professionally employed the traffic accident led to changed working conditions. The study indicates a need not only for adequate medical treatment, but also psychological and social counseling in the rehabilitation of victims of traffic accidents. Resources for crisis intervention should also be available at an early stage.

Outcome of treatment for post-traumatic stress disorder in a primary care unit serving Vietnam veterans

Veterans diagnosed with PTSD (PTSD in-treatment, N = 39), newly admitted to a comprehensive 90-day inpatient treatment program, were tracked at 4-week intervals from admission to discharge. Two control groups were also tracked over 12-week periods--one of previously PTSD diagnosed and treated veterans (PTSD out-of-treatment, N = 26), and a second that combined non-PTSD Vietnam era veterans (N = 17) and non-veterans (N = 16) (non-PTSD nontreatment). As measured by the Penn Inventory for PTSD, 48% of those who completed treatment showed some or substantial gains, 39% showed no gain, and 13% reported some increase in symptoms at the time of discharge. Several patterns were observed on other assessment measures. One year follow-up for those who completed treatment showed a return to pretreatment levels on the PTSD symptom measures employed in this study. These results are discussed in relation to other treatment program outcome studies as a baseline for further research.

The concept of the Second Generation program in the treatment of post-traumatic stress disorder among Vietnam veterans

The concepts of First and Second Generation treatment programs for Vietnam veterans with post-traumatic stress disorder are presented, based on a developmental theoretical model of adaptation. First Generation programs focus on accessing and then working through the effects of the war trauma and aim to diminish the intensity of core PTSD symptoms. Second Generation programs focus on reintegrating veterans into the social context of family and work, and aim to improve their ability to function in society. Both types of treatment may be required in order to help veterans resume their psychological and social development. The need to develop sophisticated models of comprehensive inpatient treatment in order to support scholarly discourse and outcome research is emphasized.

Substance abuse and post-traumatic stress disorder comorbidity

This article reviews the extant literature on substance abusers with and without a comorbid diagnosis of post-traumatic stress disorder (PTSD) and reveals the discontinuity between clinical lore and empirical research. Included is an overview of PTSD-substance abuse theoretical models and comorbidity prevalence rates, as well as an evaluation of the comparative data on treatment outcome and psychosocial factors, such as coping skills, for PTSD versus non-PTSD substance abusers. In addition, we discuss the controversy surrounding sequential versus simultaneous treatment approaches for such 'dually-diagnosed' patients. We conclude by identifying gaps in current knowledge about the nature and impact of PTSD on substance abuse treatment outcome and outlining needs for future research.

Road to recovery. Post-traumatic stress disorder: the hidden victim

1. Post-traumatic stress disorder (PTSD) is characterized by the development of a set of specific symptoms following a psychologically distressing event that is outside the range of usual human experience. 2. Recovery does not seem to feel as difficult or overwhelming if it is approached "one day at a time." 3. The psychologic damage that occurs in PTSD is due primarily to holding the experiences inside, "stuffing" them down through various psychodynamics, or keeping the experiences subdued through addictive behaviors. 4. PTSD among Vietnam veterans is not a mental illness; it is a reaction to extreme stress and a reaction to keeping memories stuffed down and not allowed to surface.

Neglected victims of murder: children's witness to parental homicide

Children who witness parental homicides are emotionally traumatized, stigmatized, and deeply scarred by a terrifying event. They often exhibit debilitating symptoms comparable to those of posttraumatic stress disorder. As attention is focused on the deceased and on the perpetrator of the crime, the child witnesses inadvertently become the neglected victims. A case report of two such children who observed their mother being murdered by their father is presented. Theories of psychosocial development and social learning guided the assessment and intervention phases. Behavioral and expressive therapeutic treatment strategies that helped the children work through the resultant anxiety and underlying grief are delineated, and family intervention practices that served to improve interaction and communication patterns are described. Further discussion focuses on the potential intergenerational cycle of violence and on a sociocultural perspective of family violence within an ecological framework.

Risk of retraumatisation of asylum-seekers in Australia

Australia has a long legacy of providing asylum to refugees who, it is now well established, suffer high rates of psychological and psychiatric problems requiring specialised treatment. In this paper we outline the special stressors faced by asylum-seekers who have not obtained formal refugee status and who are at risk of being forcibly repatriated. We suggest that the experiences they undergo in Australia, particularly that of prolonged detention, risk retraumatising an already vulnerable group. The implications for policy formulation are considered.

Hypnosis--a neglected tool for client empowerment

Clinical hypnosis is a valuable treatment modality that deserves to be more widely known and used by social workers. The author presents an overview of this growing clinical specialty, distinguishing between directive, Ericksonian, and permissive hypnosis. The latter, which is the most common style in use today, is based on a clear contract in which a hypnotherapist helps a client develop and use his or her own hypnotic abilities toward therapeutic goals. Characteristics of a hypnotic trance and the differing capacities of individuals in trance are presented. The article describes how permissive hypnosis is used in practice and identifies the types of clients for whom it is suitable. The author stresses the consistency of modern clinical hypnosis with social work aims and values.

Sexually and physically abused adolescents: an empirical search for PTSD

Recently, clinical manifestations of post-traumatic stress disorder (PTSD) in children and adolescents have been investigated, yet little is known about its assessment or diagnosis. Few empirically based studies appear in the PTSD literature on non-adult populations. Data were collected from 19 physically and sexually abused adolescents (aged 13-18 years) who were living in a group home setting. Subjects were administered the MMPI, Beck Depression Inventory (BDI), and Spielberger State Trait Anxiety Inventory (STAI). Results suggest that the subjects were moderately depressed and anxious, but that these adolescents did not manifest significant symptomatology of PTSD similar to that seen in adult, civilian PTSD populations using comparable MMPI measures. Implications of these findings for assessment purposes are discussed.

Victims of the intifada: the psychosocial adjustment of the injured

This empirical study assessed the psychosocial adjustment of the Palestinians who sustained serious bodily injuries during the intifada. Research dealt with the personal and interpersonal forces that impede or facilitate adjustment, with the mediating effect of social support and with the special services provided by local institutions. Findings suggested that a lapse of time did not improve adjustment. The level of education and marital status had an apparent effect on adjustment. An individual's adjustment correlated positively with situational variables, whereas it was negatively affected by trauma-related variables. Implications for future research, coping strategies, and rehabilitation plans are discussed.

Alcoholism and drug abuse in patients with PTSD

The combination of PTSD and substance abuse is both common and problematic. In this chapter we review the following questions: 1) What is the relationship between PTSD, Alcoholism, and Drug Abuse? 2) Can the general "dual diagnosis" literature be of help? 3) Is the phenomenology of PTSD combined with alcoholism and/or drug abuse either unique or specific? 4) Does current pathophysiologic data allow conceptualization of a neurobiological model of PTSD, alcoholism, and drug abuse? 5) Drawing on these ideas, on the limited treatment literature, and the "dual diagnosis" literature, can we develop rational assessment and treatment approaches? Available literature suggests that diagnoses can be validly applied to these patients; that the illnesses must be treated simultaneously as co-primary illnesses; that extreme psychological symptoms reduce the efficacy of alcoholism or drug abuse treatment; and that effective control of these symptoms improves treatment outcome.

Mothers of sexually abused children: trauma and repair in longitudinal perspective

Mothers whose children had been sexually abused reported experiencing serious psychological symptoms following disclosure of the abuse. Over a one-year period, their emotional status improved. Strong relationships between mothers' reports of their own and their children's symptoms were accompanied by persistent discrepancies between maternal and direct assessments of the children's emotional states. Findings suggest that addressing maternal distress is important to the study and treatment of child sexual abuse.

Graded Work Exposure to Promote Work Return after Severe Hand Trauma

Fifty-one patients with posttraumatic stress disorder after work-related hand injuries were placed on a graded work exposure program to facilitate return to work. These patients consisted of an initial group of 25 patients and a replication group of 26 patients. The program returned 92% of the initial group and 88% of the replicated group to work with their previous employers. At 6-month follow-up, 88% of the initial group and 80.1% of the replication group were still working full-time at the jobs to which they had returned. All of the patients not working with their previous employer at follow-up had appraisal/projected flash-backs, which have previously been associated with a 90% failure to return to work. This intervention was successful with 73% of the patients experiencing such flashbacks. In conclusion, graded work exposure was an effective treatment to promote return to work for patients experiencing significant psychological symptomatology after severe hand injury.

Posttraumatic stress disorder among homeless men and women

Six hundred homeless men and 300 homeless women in St. Louis were systematically interviewed using the revised Diagnostic Interview Schedule that includes a module for assessment of posttraumatic stress disorder (PTSD). Most subjects with PTSD had an additional life-time psychiatric diagnosis. No consistent pattern of association was apparent, however, between individual diagnoses and either traumatic events or PTSD. In almost three-fourths of both men and women, the onset of PTSD had preceded the onset of homelessness. Childhood histories of abuse and family fighting were predictive of both traumatic events and PTSD. The results suggest that factors leading to PTSD in the study sample began long before the onset of homelessness and may overlap with factors operative in the genesis of homelessness.

Psychosocial needs of torture survivors

Growing recognition that the world faces a modern epidemic of torture has stimulated widespread interest amongst mental health professionals in strategies for the treatment of survivors. In this article we outline the distinctive experiences of torture survivors who present for treatment in western countries. These survivors are usually refugees who, in addition to torture, have suffered a sequence of traumatic experiences and face ongoing linguistic, occupational, financial, educational and cultural obstacles in their country of resettlement. Their multiple needs call into question whether "working through" their trauma stories in psychotherapy will on its own ensure successful psychosocial rehabilitation. Drawing on our experience at a recently established service, we propose a broader therapeutic aim.

The development of the New South Wales Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS): the first year

Many immigrants to Australia are refugees, some of whom have experienced acute stress and trauma, including torture, prior to or during their escape from their home countries. In response to a growing recognition that the health care services may not be meeting the needs of these people the NSW Department of Health funded the establishment of a community-based rehabilitation service for traumatised refugees. This paper provides an overview of the recent history of the service, some of the organisational and staffing issues faced during its first year, some characteristics of the first 200 clients, principles of treatment, clinical, nosological and therapeutic issues and relationships with other agencies.

Vocational rehabilitation for psychiatric inpatient Vietnam combat veterans

A Department of Veterans Affairs (DVA) inpatient psychiatry program treating Vietnam veterans for symptoms of posttraumatic stress disorder provided day and evening treatment programs. The evening program, besides treating psychiatric trauma, incorporated the DVA mission of assisting patients with vocational rehabilitation and work force reentry. Although initially opposed to employment, Vietnam veterans accepted a treatment program with an emphasis on working and job training. Both programs were compared using the Ward Atmosphere Scale (WAS). No significant differences between the two programs were found. The results support the DVA's position that employment is a valuable component of psychiatric treatment.

Massachusetts' post-traumatic stress disorder program: a public health treatment model for Vietnam veterans

Post-traumatic stress disorder (PTSD) can be a serious aftermath of catastrophic events such as war. The incidence of PTSD appears to be high among Vietnam veterans. PTSD can be extremely disruptive to a person's physical and mental well-being, family life, social relationships, and employment status. Yet, for a variety of reasons, many Vietnam veterans suffering from PTSD have remained undiagnosed or insufficiently treated. The Massachusetts Department of Public Health, in cooperation with the Massachusetts Department of Veterans Services, initiated a hospital-based treatment and rehabilitation program for Vietnam veterans who have PTSD. As of November 1989, 150 Vietnam veterans had been admitted to this program.

Therapeutic considerations with adult children of alcoholics

Children from alcoholic homes frequently develop defenses similar to those found in children who have been physically abused. During adulthood these defenses lead to over-control of one's emotions and interpersonal interactions. Therapeutic implications involve management of grief reactions as illusions of the "good" parent are relinquished.