Andrei Novac, MD

In spite of major strides made in the study of posttraumatic stress disorder, our full understanding of trauma as a phenomenon, its mechanisms of actions, and its long-term consequences on the human brain and social behavior is limited. It appears that trauma is a virtual impact between an event (the traumatic event) and the individual (the victim). Both opponents in this impact, however, arrive with a variety of factors and may equally contribute to the outcome. Thus, trauma is an equation with two variables that determine a potential for myriad outcomes. For mental health care professionals, traumatic phenomenology ranges from organized psychiatric syndromes to individual behaviors that often shape the history and legacy of one generation. 

Besides being relevant topics for the contemporary clinician, the articles that follow can be closely linked to major social-historical events of the past 100 years. As discussed in the article by Charles Portney, M.D., intergenerational transmission of trauma as a clinical manifestation became known after the Holocaust and the treatment of its survivors. The article by Rachel Yehuda, Ph.D., reminds us of the Vietnam War and the political upheavals of the 1960s and '70s, when the designation PTSD emerged. In discussing secondary traumatization of mental health care professionals and trauma and violence in childhood, Rose Zimering, Ph.D., and colleagues refer to concepts that underscore the complications of trauma treatment and the need for adequate resources for a more sophisticated mental health care system. Additionally, Yuval Neria, Ph.D., and colleagues bring us to the daunting present.

Currently, psychiatry is exploring the pathological consequences of trauma that easily fit into the DSM: PTSD and depressive anxiety and substance abuse disorders. It is time that we extend this inquiry to the more complex social and group victimizing behaviors that usually remain off-limits for the field of mental health. Some studies have pointed to the added burden on the brain of childhood trauma history in individuals with depressive disorders (e.g., 

 2002;159[12]:2072-2080). This confirms suggestions that trauma per se is a pathogen that may result in a wider spectral variety of manifestations (

 2002;25[4]:775-790), some of them behavioral peculiarities encountered in society. 

As the United States is once again facing another war, consideration has to be given to the long-term and long-long-term consequences of trauma at all levels. We may feel consoled to recognize that during the most perilous times, humankind has concentrated its wisdom, talent and ingenuity to circumvent the catastrophes of war. However, mental health care professionals remain responsible for objectively educating society in an apolitical manner about the effects of witnessing killing and the destruction of civilian life as well as the real effects of trauma on any nation. 

Psychiatric Times gratefully acknowledges Dr. Novac for his guidance in preparing this special report section. 

Articles

In this introduction to our Trauma Special Report, Dr. Novac places the articles in historical perspective and reminds the reader of the importance of understanding trauma within today's global constructs and impending war.

Global and Social Considerations

In the past decade, environmental factors of mental illness have often been neglected. Patients with a history of traumatic stress are notoriously treatment-resistant. 

 is rare. I have previously pointed to the fact that trauma-related psychopathology and/or trauma-related behavioral patterns may be on the rise (Novac, 2001). Consequently, the prevalence of a variety of comorbid mood dysregulations (including mixed bipolar and atypical depression) and residuals of posttraumatic stress disorder (PTSD) is expected to increase in the future. This prompted the release of practice guidelines by the International Society of Traumatic Stress (Foa et al., 2000). A glance at the table of contents shows the numerous treatments currently used for PTSD. Specialized trauma centers tend toward a multimodal eclectic approach, further supporting the variability in treatment response of patients with PTSD (Foa et al., 2000).

Psychotherapy should be conducted in a predictable, quiet environment. In treating trauma patients, therapists should evaluate the office for possible reminders of the traumatic event (Clinical Case 1). Minor details can be very effective in making the patient more comfortable. For instance, the same receptionist should always be available for trauma patient intake. Here, more than anywhere else, familiarity, predictability and individuality create an atmosphere conducive to healing.

Most often, trauma patients want to know what the therapist's personal experience with trauma has been. Such credentialing is important for many trauma patients before they can open up and trust. A concise presentation of how the therapist understands and respects trauma patients is necessary. This can be done safely without creating boundary problems and will lead to a strengthening of the therapeutic alliance. Such personal revelations are advisable and seem to be a major difference between treating trauma survivors and other patient populations (Wilson and Lindy, 1994).

Acutely dysphoric patients may have a resonating effect on the hyperaroused patient with PTSD. Hence, polytraumatized individuals may need to be separated from dysphoric crisis patients. 

The importance of addressing the impact of trauma on marriage and family early in treatment has been recognized (Figley, 1988). Supportive and active techniques are most commonly used. Marital and family therapy aims toward the preservation of the family unit as an important support system for patients with PTSD. The possibility of secondary traumatization of family members, including that of children (intergenerational transmission of trauma) should also be systematically explored (Clinical Case 2). 

Currently, most trauma patients are privately treated by one clinician. Tertiary institutions should serve as a support for the trauma community. Case presentations, educational events and communication between trauma therapists are excellent network enhancers. In teaching hospitals, trauma services should be led by more seasoned clinicians with good ties to the community of practitioners. They also must be well versed in the dynamics of groups and organizations in order to rapidly address difficult cases of countertransference. Experienced trauma clinicians should always be available for consultations in the form of support, debriefing and professional supervision (Clinical Case 3). Unfortunately, in spite of a large body of theoretical literature, too often empathy is discussed late in student and resident training. At times, overworked nursing staff exhibit empathic failure and diminished listening skills. 

Symptoms of trauma patients and some Axis II patients are sometimes considered part of the same continuum. However, in recently traumatized patients, ego-dystonic symptoms are prevalent. Empathy cannot be separated from the transference/countertransference paradigm. 

In this regard, Atwood and Stolorow (1984) described two common situations: 1) conjunctive countertransference, where the patient's experience resonates with and is assimilated by the internal experience of the therapist, which enhances empathy and facilitates the therapeutic process and 2) disjunctive countertransference, whereby the therapist alters the meaning of the patient's experience in accordance with their own history, which can result in the patient feeling misunderstood. To correct disjunctive countertransference, the therapist can create new points of reference and reset themselves into an empathic mode of understanding the patient's subjective experience. 

Empathic strain may often lead to premature termination of therapy, neglect and retraumatization of the patient. A permeable boundary -- a flexible balance between empathy and limit setting -- will encourage the development of healthy boundaries for the injured person. McCann and Colletti (1994) referred to the alternation between an empathic position of the therapist and the phenomenon of being understood by the patient as an "empathic dance," which facilitates understanding and propels the effectiveness of the therapeutic process.

The regressive effect of trauma often gives rise to a transference that associates the therapist with victimhood, shame and demanding assumptions. Therapists may respond with complementary reactions. Two major patterns have been described: 1) avoidant countertransference, in which the therapist distances themselves from the traumatic stories and the patient and 2) overidentification countertransference, in which faulty boundaries may lead to the therapist feeling overwhelmed, exhausted and ineffective (Wilson and Lindy, 1994). 

A multitude of factors can influence the particular type of countertransference invoked: the nature of stressors, the trauma stories, the therapist's personal beliefs and perceptions, the patient's demographics or personality characteristics, and institutional factors such as attitudes toward trauma patients and adequacy of resources. With special trauma patients (e.g., victims of genocide or war), countertransference factors may originate in the greater societal context, i.e., prevalent attitudes toward certain events or trends in psychotherapy. In the case of man-made traumatic events, the therapist has to confront the evil side of mankind, which has been referred to in the literature as 

 (Danieli, 1994). Under such circumstances, the countertransference often becomes directed toward the trauma per se. 

A good knowledge base of the historical context of traumatic events is tantamount. Danieli (1981b) described an early reaction to survivors of the Holocaust, where psychotherapists, families and society adopted a suppressive attitude, referred to as a "conspiracy of silence." The failure of therapists, families and society to share part of the patient's pain has been referred to as a 

The therapist's adverse reactions to trauma patients has been described under different constructs: burn-out (Freudenberger and Robbins, 1979), which includes symptoms of depression, cynicism, boredom, loss of compassion and discouragement; secondary victimization (Figley, 1983), where therapists and others who are close to the victim develop symptoms similar to that of the victim, including PTSD; or countertransference (Danieli, 1981a; Lindy, 1988). 

Drawing on constructivist self-development theory, McCann and Pearlman (1990a) described a profound change in some therapists who work with traumatized individuals. Here the therapist's beliefs, expectations and assumptions about the world are changed by repeated exposures to the patient's traumatic events. Such therapists may become distrustful, suspicious, cynical and often adopt thoughts and images about their own personal vulnerability. At times, images similar to those reported by their patients may be triggered by relatively benign stimuli outside work (McCann and Pearlman, 1990b). Therapists affected by vicarious traumatization may develop diminished esteem for other people or the human race in general, which results in feelings of bitterness and pessimism. In time, vicarious traumatization deeply affects the therapist's personal life and the ability to maintain a therapeutic stance. 

Intervention must be preventive, by a modified type of case conference in which countertransference can be processed (McCann and Pearlman, 1990b). Personal consultation, psychotherapy, support groups and professional organizations may all maintain the functionality of the trauma community, especially when centered around a local tertiary teaching hospital.

The treatment of traumatized patients is complex and necessitates adequate training, an eclectic and flexible approach toward the patient, and an adequate support structure for therapists by other professionals, community and tertiary referrals. Extensive knowledge and understanding of countertransference, empathy and secondary traumatization is crucial. In spite of the many pitfalls, including consequences on the mental well-being of a trauma therapist, there is a great potential for personal growth, pioneering research and professional mastery in the field of traumatic stress.

 Atwood GE, Stolorow RD (1984), Structures of Subjectivity: Explorations in Psychoanalytic Phenomenology. Hillsdale, N.J.: Analytic Press.
 

 Danieli Y (1981a), Therapists' difficulties in treating survivors of the Nazi Holocaust and their children. Doctoral dissertation, New York University.
 

 Danieli Y (1981b), Differing adaptational styles in families of survivors of the Nazi holocaust. Child Today 10(5):6-10.
 

 Danieli Y (1994), Countertransference, trauma and training. In: Countertransference in the Treatment of PTSD, Wilson JP, Lindy JD, eds. New York: Guilford Press, pp368-388.
 

 Figley CR (1983), Catastrophes: an overview of family reaction. In: Stress and the Family: Coping with Catastrophe, vol. 2, McCubbin HI, Figley C, eds. New York: Brunner/Mazel, pp3-20.
 

 Figley CR (1988), A five-phase treatment of post-traumatic disorder in families. Journal of Traumatic Stress 1:127-141.
 

 Foa EB, Keane TM, Friedman MJ (2000), Effective Treatments for PTSD. Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press.
 

 Freudenberger HJ, Robbins A (1979), The hazards of being a psychoanalyst. Psychoanal Rev 66(2):275-296.
 

 Lindy JD (1988), Vietnam: A Casebook. New York: Brunner/Mazel. 
 

 McCann IL, Colletti J (1994), The dance of empathy: a hermeneutic formulation of countertransference, empathy, and understanding in the treatment of individuals who have experienced early childhood trauma. In: Countertransference in the Treatment of PTSD, Wilson JP, Lindy JD, eds. New York: Guilford Press.
 

 McCann IL, Pearlman L (1990a), Through a Glass Darkly: Understanding and Treating the Adult Trauma Survivor Through Constructivist Self-Development Theory. New York: Brunner/Mazel.
 

 McCann IL, Pearlman L (1990b), Vicarious traumatization: a framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress 3:131-149.
 

 Novac A (2001), Traumatic stress and human behavior. Psychiatric Times 18(4):41-43.
 

 Symonds M (1980), The 'second injury' to victims. In: Evaluation and Change: Services for Survivors, Kivens L, ed. Minneapolis: Minneapolis Research Foundation, pp36-38.
 

 Wilson JP, Lindy JD (1994), Empathic strain and countertransference. In: Countertransference in the Treatment of PTSD, Wilson JP, Lindy JD, eds. New York: Guilford Press.

Treating traumatized patients requires special care so that both therapist and patient can benefit from the relationship. How can therapists facilitate this care, and what can they do to keep themselves healthy while treating such patients?

Special Considerations in the Treatment of Traumatized Patients

The past 100 years have been characterized by rapid development of technology, major sociopolitical changes and substantial growth in knowledge about human biology, behavior and the brain. These changes have been paralleled by an ever-increasing speed with which information and news are transmitted around the world. For instance, news of natural disasters, catastrophes and genocides are made widely available, instantaneously, via 24-hour cable news networks, creating an enormous pool of spectators to regional negative events. 

This is significant, as the study of traumatic stress has determined that not only victims but also those being confronted with and witnessing traumatic events may be vulnerable to posttraumatic stress disorder (PTSD) (American Psychiatric Association, 1994). There is some evidence that man-made and man-induced traumatic stress is more traumatogenic and more likely to cause psychopathology than natural disasters (Breslau et al., 1991). After a century that claimed approximately 200 million lives in military conflicts and genocide, it becomes particularly important to examine the origins and consequences of traumatic stress and preventive modalities.

In the 1980s, the establishment of diagnostic criteria for PTSD caused a more in-depth inquiry into the effects of trauma on the brain's biology. Literature has recently emerged showing that trauma constitutes the pathogen for both trauma-specific and general psychopathology.

Post-traumatic stress disorder was first described in the 

 but psychophysiological reactions to traumatic stress have been known since ancient times. Current emphasis on descriptive psychiatry has made it important to differentiate between a variety of syndromes that occur after traumatic events. PTSD has been found to be a fairly common psychiatric condition in the general population. Lifetime PTSD prevalence of 7.8% (Kessler et al., 1995) suggests that it is among the most common psychiatric disorders.

PTSD is characterized by the following triad of symptoms: 1) re-experiencing symptoms (i.e., obsessive recollections, flashbacks, nightmares); 2) avoidant symptoms; and 3) symptoms of hyperarousal. Although the 

 requires the presence of a number of such symptoms, traumatized patients more often may present a hybrid of PTSD, depressive disorder and other anxiety disorders. 

For example, some patients will present more severe symptoms of hyperarousal with severe depression. The re-experiencing of symptoms is often misdiagnosed as "obsessiveness" within a depressive disorder. Hyperarousal symptoms may be misdiagnosed as insomnia and anxiety to a major depressive episode. Other patients have predominant obsessive rumination and, thus, may be misdiagnosed with obsessive-compulsive disorder. A careful interview is necessary to elicit different, new habits that may indicate the presence of newly developed avoidant symptoms. Patients with such symptoms may have also self-medicated their hyperarousal with alcohol to mute the symptoms; this drinking is most often denied. Still other patients may experience mixed obsessive recollections with flashbacks and, at times, auditory and visual hallucinations. These patients may be misdiagnosed as dissociative or psychotic. Patients with severe insomnia, symptoms of hyperarousal, severe irritability and racing thoughts may be misdiagnosed as manics or hypermanic borderline patients. In all cases, a recent onset of symptoms and a rapid drop in level of functioning should raise the suspicion of PTSD. 

Uncovering the traumatic origins of these manifestations is important because traumatic stress seems to have a lifetime cumulative effect. Previously traumatized victims seem more likely to develop PTSD than first-time victims (Resnick et al., 1995). Among two separate populations of trauma patients, those who developed PTSD later presented lower mean levels of blood cortisol in the immediate aftermath of trauma, compared to those who developed depressive or no psychiatric condition (Resnick et al., 1995; McFarlane et al., 1997). Peri-traumatic dissociations, elevated heart rate, severe intrusive symptoms and exaggerated startle response have been identified at least in some studies as predictors of PTSD (Shalev et al., 1998; Koopman et al., 1994). 

The majority of traumatized individuals do not develop PTSD. According to Tomb (1994), in an exposed population, the frequency varies anywhere from 10% to 30%. Vietnam veterans are known to have a prevalence of 20% to 30% of PTSD, while the prevalence of PTSD in rape victims may exceed 50% during the first month, then drop to 5% after several years (Tomb, 1994). In a study of 124 Holocaust survivors, 46% were found to suffer from PTSD (Kuch and Cox, 1992). The majority of patients who survive traumatic events develop a variety of anxiety disorders (e.g., phobias and panic attacks), major depression and substance abuse disorders. Among patients with major depression, those with an earlier history of trauma are more likely to present with bipolarity and atypicality (reversed functional shifts) (Levitan et al., 1998), which would support a separate classification of "trauma-related depression." Finally, traumatic stress seems to have had an impact on the prevalence of general psychopathology as well. In fact, the stressogenic lifestyle of the 20th century seems to have led to an increase in prevalence of certain psychiatric disorders.

The environment has a significant impact on postnatal cortical development. The orbitofrontal cortex, which is in command of alternating emotional processes, may require both variety and balance between different external stimulations (both negative and positive) for adequate structural and biochemical development (Schore, 1994). The prefrontal neurotransmitter system has been found to be sensitive to environmental stress. Exposure to extreme circumstances may lead to subtle structural abnormalities in the frontal lobe, which is closely related to the limbic system. These abnormalities may further result in deep-seated personality deficits (i.e., an inability to be empathetic, pathological narcissism) that are not readily diagnosable as psychiatric disorders. This may explain why early exposure to traumatic stress or disruptive changes in environment may result in more fundamental behavioral changes that are ego-syntonic and are more often diagnosed as personality disorders. These may vary from subtle interpersonal problems to major personality disturbances, as described in the 

Some of these individuals may be prone to aggression and dehumanization of others in the service of a cause that they find noble. Such manifestations, described in a number of political leaders known to have been victims of child abuse, may not fit into a classifiable psychiatric diagnosis. The elusiveness of such dysfunctional behavior is further supported by the fact that systematic analysis of Rorschach ink blot tests obtained from Nazi war criminals did not reveal the presence of any specific mental illness (Zillmer et al., 1995). In summary, the increase in prevalence of traumatic stress over the past century may explain, in part, the increase in behavioral syndromes with less well-defined boundaries. This is consistent with earlier reports (Sass, 1982) linking personality pathology to less structured family environments. Individuals with "deficits of the self" may become new sources of trauma in society.

A body of literature on the behavioral changes exhibited by victims of trauma has emerged over the past decade. Behavioral changes that occur in the absence of classifiable psychopathology have been examined in survivors of domestic violence, natural disasters and the Holocaust; results of such can be found elsewhere (Novac et al., 1999). The study of intergenerational transmission of trauma began with descriptions of trauma-induced behavior transmitted from Holocaust survivors to their children (Felsen, 1998). Early accounts were mainly anecdotal, reported by clinicians and interpreted mainly as psychodynamic processes occurring during early development. However, a 1998 systematic study by Yehuda et al. confirmed that offspring of Holocaust survivor parents with PTSD have a higher lifetime risk for PTSD and report more distress after traumatic events. Thus, besides the exposure to their parents' traumatic stories and their trauma-related acquired behavioral patterns, these offspring may have a biological vulnerability to traumatic stress and PTSD transmitted to them from their parents (Novac and Hubert-Schneider, 1998). In 1998, Suomi and Levine reported intergenerational transmission of trauma in primates. As a result, Novac and Hubert-Schneider (1998) hypothesized that there is a phylogenetically determined survival mechanism by which primates and humans pre-sensitize and prepare their offspring for dangers.

Numerous contributions on PTSD have not clarified whether traumatic stress is a normal reaction to unusual circumstances or a pathological response to stressors routinely encountered (Yehuda and McFarlane, 1995). Surviving traumatic stress most likely results in an entire spectrum of behaviors, some of which may be attributable to psychopathology, while others may be adaptational styles. Traumatized individuals may transmit a certain vulnerability to stress to their offspring. Amazing accomplishments in modern societies may have overextended, at times, the boundaries of compensatory biological systems, creating an environment that is suboptimal for time appropriate maturation of certain brain areas. These same environmental factors, however, may have also resulted in behavioral diversity, social plurality and a quest for tolerance.

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In this overview of research into the biopsychosocial changes caused by traumatic events, Dr. Novac discusses psychopathology, brain development and the effect a traumatic event can have on the victim's family-even long after the event occurred.

Author | Andrei Novac, MD

Articles

Global and Social Considerations

Special Considerations in the Treatment of Traumatized Patients

Traumatic Stress and Human Behavior