Posttraumatic Stress Disorder (PTSD)

Assessment. Clinical assessment of posttraumatic stress involves the traditional methods of evaluation. The history of exposure, prior trauma, and pre-existing and co-morbid conditions must be assessed. In some situations, such as natural disasters or reported criminal victimization, exposure to trauma is obvious, and the clinician quite naturally inquires about the signs and symptoms of PTSD. In other situations, however, exposure is obscure, and the need for evaluation may be less obvious. Children may not spontaneously report their symptoms, and adults may underestimate trauma in children (Almqvist and Brandell-Forsberg 1997; Handford et al. 1986; Yule and Williams 1990), making it essential to ask children themselves about their experiences and reactions. In addition, children may have difficulty understanding concepts such as avoidance and numbing; therefore, evaluation of them should include observation and reports by parents, teachers, and/or other adults.

Treatment. Treatment involves transforming the individual's self-concept from victim to survivor as the trauma is resolved in a safe setting in which painful and overwhelming experiences can be explored (Amaya-Jackson and March 1995; Gillis 1993; Hollander et al. 1999). Avoidance, a core symptom of PTSD, may prevent the victim from seeking or continuing treatment (Ehlers 2000). The therapist, therefore, must consider omitted information and associated feelings and affects. Avoidance can be protective, decreasing suffering temporarily, but it may be interrupted by intrusive experiences and heightened arousal that occur spontaneously or with exposure to traumatic cues. Educational information is an important aspect of the treatment of PTSD, especially when anxiety and avoidance discourage the patient from seeking or continuing treatment. Prior traumatic experiences must be explored and co-morbid symptoms such as anxiety and depression must be identified and treated. A variety of modalities are used to treat PTSD, although the comparative effectiveness of various modalities has received little attention.

Psychotherapeutic and cognitive-behavioral approaches. The literature suggests that crisis intervention, individual and group therapy, play A pediatrician and a young patient participate in art therapy. Projective treatment methods such as art therapy allow victims of PTSD to explore traumatic events in a less threatening manner. ED ECKSTEIN/CORBIS therapy for children, therapeutic exposure, desensitization, relaxation, other cognitive-behavioral techniques, and pharmacotherapy are beneficial in treating PTSD (Davidson 1995; Terr 1989). Exposure therapy that involves repeated review of the traumatic experience is a component of many approaches. Use of projective techniques such as play in children and art may provide access to traumatic themes without threatening the victim's defensive structure. Relaxation techniques may decrease arousal, tension, physical symptoms, anxiety, and sleep disturbance (Hollander et al. 1999). Hypnosis can also be effective (Davidson 1995; Ehlers 2000; Hollander et al. 1999; Terr 1989).

Pharmacotherapy. Pharmacotherapy is an adjunctive treatment that may be needed if symptoms are disabling (Amaya-Jackson and March 1995; Hollander et al. 1999; Marmar et al. 1994). A variety of drugs are potentially effective, most notably anxiolytics (agents that dispel anxiety) and antidepressants. Specific symptoms and the stage of the illness determine whether to use a drug, what drug to use, and the duration of use. Positive symptoms of re-experiencing and arousal may be more responsive to medication than negative symptoms of avoidance (Marmar et al. 1994). Co-morbid conditions should be considered in selecting an agent.

Family therapy. Family work is an excellent means of providing education about trauma and what to expect over time. Parents of traumatized children may benefit from psychoeducation about their children's symptoms and how to effectively manage them. Often, more than one family member will be traumatized though individual exposure and the course of the illness and recovery may differ. Parental trauma may be so great that the needs of a young child may be overlooked. Helping parents resolve their own emotional distress can increase their perceptiveness and responsiveness to their children. The focus of family work includes validating the experiences and emotional reactions of each family member, helping family members regain a sense of security, anticipating situations in which additional support will be needed, and exploring ways to decrease traumatic reminders and secondary stresses.

Group treatment. Group work is ideal for educating victims about symptoms and the posttraumatic course. Sharing with others who have experienced the same or similar trauma can be reassuring, but some are uncomfortable sharing in a group. Group discussions may be re-traumatizing through re-exposure to one's own experiences or through exposure to the experiences of others. Group work also provides an expedient means of reaching individuals in need of more intensive individual assistance.

School-based efforts. School-based interventions are effective for traumatized children or children at risk for trauma. They provide access in developmentally appropriate settings that encourage normality and minimize stigma.

Long-term treatment and pulsed interventions. Long-term treatment may be necessary for those with intense or enduring exposure and symptoms, pre-existing or co-morbid conditions, prior or subsequent trauma, or family problems. Treatment during the acute phase of trauma may be followed by planned interventions at strategic points. These may be especially important following mass casualty events when many have been exposed and can be reached for follow-up in groups. Periodic, brief interventions are useful during developmental transitions and at anniversaries.