Biological Stress Systems and Brain Development
in Maltreated Children With PTSD
Michael D. De Bellis, MD
Western Psych. Institute & Clinic
Child maltreatment is increasing in the United States and may be the most common cause of interpersonal traumas and posttraumatic stress disorder in children and adolescents (De Bellis 1997). Developmental Traumatology, the systematic investigation of the psychiatric and psychobiological impact of overwhelming and chronic interpersonal violence on the developing child, is a relatively new area of study. It synthesizes knowledge from an array of scientific fields, including developmental psychopathology, developmental neuroscience, and stress and trauma research. One active area of research involves the effects of maltreatment and related stressors on major body stress response systems such as the hypothalamic-pituitary-adrenal axis, the catecholamine system the locus ceruleus-norepinephrine/sympathetic nervous system, and the immune system (De Bellis and Putnam 1994).
Recent research at Western Psychiatric Institute and ClinicUs Developmental Traumatology Laboratory suggests that the overwhelming stress of childhood maltreatment is associated with alterations of biological stress systems and with adverse influences on brain development (De Bellis et al 1999a; De Bellis et al 1999b). In one study, 18 prepubertal maltreated children with PTSD, nontraumatized children with DSM-III-R overanxious disorder (N=10), and healthy controls (N=24) underwent 24 hour urine collection for measurements of urinary free cortisol, a reflection of HPA axis regulation, and urinary catecholamine excretion. Maltreated subjects with PTSD excreted significantly greater amounts of UFC and catecholamines than nonabused controls. These biological stress measures correlated positively with duration of the PTSD trauma and symptoms of intrusive thoughts, avoidance, and hyperarousal (De Bellis et al 1999a).
In a second study, 43 maltreated children and adolescents with PTSD and 61 matched controls underwent comprehensive clinical assessments and an anatomical magnetic resonance imaging brain scan. Maltreated subjects with PTSD had 7.0 % smaller intracranial and 8.0% smaller cerebral volumes than matched controls.
The total midsagittal area of corpus callosum, the major interconnection between the two hemispheres that is broadly conceptualized as facilitating intercortical communication, and the middle and posterior regions of the corpus callosum, were smaller in abused subjects.
In contrast, right, left, and total lateral ventricles were proportionally larger than controls, after adjustment for intracranial volume. Intracranial volume robustly correlated positively with age of onset of PTSD trauma (i.e., smaller brains were associated with earlier onset of trauma) and negatively with duration of abuse.
Symptoms of intrusive thoughts, avoidance, hyperarousal and dissociation correlated positively with ventricular volume, and negatively with intracranial volume and total corpus callosum and regional measures. The decreased hippocampal volume reported in adults with PTSD was not found in the subjects (De Bellis et al 1999b).
These data suggest that chronically maltreated children with a diagnosis of PTSD manifest alterations of major biological stress systems including adverse influences on brain development. Although based on a cross-sectional analysis, thus causation can not be proven, these findings are intriguing and may have important social policy and treatment implications. Elucidating the biological sequelae and mechanisms of symptom production in PTSD and associated comorbid psychiatric disorders will pave the way to better clinical and social treatment of abused children. Accordingly, prospective longitudinal studies in developmental traumatology are critical to the effort to develop early interventions to attenuate the psychobiological dysregulation and adverse effects on brain development associated with maltreatment.
De Bellis, M.D. (1997). Posttraumatic stress disorder and acute stress disorder. In Ammerman RT, Hersen M (eds.), Handbook of Prevention and Treatment with Children and Adolescents. New York: John Wiley & Sons Inc., 455494.
De Bellis, M.D., Baum, A., Birmaher, B., et al. (1999a). A. E. Bennett Research Award. Developmental Traumatology: Part I: Biological Stress Systems. Biological Psychiatry, in press.
De Bellis, M.D., Keshavan, M., Clark, D.B., et al. (1999b). A.E. Bennett Research Award. Developmental Traumatology, Part II: Brain Development. Biological Psychiatry, in press.
De Bellis, M.D., Putnam, F. W. (1994). The Psychobiology of Childhood Maltreatment. In Child and Adolescent Psychiatric Clinics of North America 3:663677.
This work was supported primarily by the 1995 NARSAD Young Investigators Award, "Attention and Concentration in Maltreated Children with Posttraumatic Stress Disorder" and by NIMH Grant
No. 5 K08 MHO132402.
ISTSS Treatment Guidelines to be Published in late 1999
The ISTSS board of directors has identified the development of PTSD Treatment Guidelines as a priority for the Society. Hence in November 1997, the board established the PTSD Treatment Guidelines Task Force co-chaired by Edna Foa, Terence M. Keane, and Matthew Friedman. The guidelines are intended to inform the clinician about treatment of individuals with PTSD.
The co-chairs assembled the task force by identifying experts in the major schools of therapy and treatment modalities that are currently employed with patients who suffer from PTSD. The task force was expanded as additional relevant treatment approaches were identified.
Thus, the task force represented experts across approaches, theoretical orientations, schools of therapy, and professional training. The focus of the guidelines and its format was determined in a series of meetings.
The co-chairs commissioned position papers on the major treatment areas or modalities from task force members. Each paper was written by a designated member with assistance from other members or clinicians, as deemed necessary. The position papers included a literature review of research and clinical practice. The position papers address the following areas related to PTSD:
- Psychological Debriefing;
- Cognitive Behavior Treatment;
- Treatment of Children and Adolescents;
- EMDR and Other Neoteric Approaches;
- Group Psychotherapy;
- Psychoanalytic Psychotherapy;
- Inpatient Treatment;
- Psycho-social Rehabilitation Techniques;
- The Use of Hypnosis;
- Marital and Family Therapy; and
- Creative Arts Therapies.
Based on the position papers, and careful attention to the literature review, a draft of practice guidelines for each treatment approach was developed. In the guidelines, each treatment approach or modality was assigned ratings with respect to strength of evidence regarding its efficacy. The ratings were standardized, using a coding system adapted from the Agency for Health Care Policy and Research (AHCPR, U.S. Department of Health and Human Services, Public Health Service).
The guidelines were reviewed by the task force for concurrence, sent for review to a broad range of professional associations, presented at a public forum at the ISTSS annual meeting in November 1998, and placed on the ISTSS Web site in March 1999 for comments from the membership.
The proposed guidelines were presented to the board at the ISTSS annual meeting in 1998 and will be discussed during the mid-year board meeting in 1999.
The PTSD Treatment Guidelines will be published by Guilford Publications Inc. in late 1999. The task force plans to include comments from the membership gathered through the Web in the final publication.
Growth and Divergence -- A Necessary Struggle?
Alexander C. McFarlane, MD
To agree or disagree, that is the question. Do we sustain our relationships by focusing on the issues of mutual acceptance or by struggling with the points of difference? These questions are relevant to both the formations of social structures and personal relationships.
ISTSS is an organization forged out of disparate social groups. As Sandra Bloom has characterized in her recent history of the origins of the society (See Traumatic StressPoints, Vol. 12, Nos. 2 and 4; Vol. 13, No. 1 ), ISTSS emerged from an unusual conglomerate of social and clinical advocates. They were bound together by focus and the issues could be stated unambiguously. The social forces and prejudice that had to be overcome tightly bound this coalition.
Growth means divergence. The emergence of knowledge only increases ignorance and uncertainty. Parents of adolescents know the difficulty reining the burgeoning enthusiasm and rebellion against authority that comes with maturation. A major challenge of ISTSS is how to maintain group identification without constraining individuality.
The spirit of this struggle has been in part reflected by the development of the Treatment Guidelines Committee. The process of achieving a consensus around issues of treatment involves the collision of science with art, opinion with fact and advocate with skeptic. The debate and tensions surrounding the development of the treatment guidelines are a test of the maturity of the ISTSS and its members.
The 15th annual conference in Miami will focus on how to maintain the bridges between the competing needs of different groups. In the treatment arena, the evidence for the effectiveness of treatment lags behind clinical practice. Furthermore, much of the treatment literature is based on studies conducted by groups of experts in highly selected subsamples of populations.
While the findings of this research are critical to evidence-based practice, their applicability to general clinical settings and the demonstration of similar effects in general clinical samples is an underdeveloped area of research. This is particularly relevant with traumatized patients because their distress significantly disrupts their ability to hold themselves in treatment relationships. The treatment setting demands confrontation with memories when the individual's characteristic way of adaptation has often been to avoid recall of the trauma. The ability to cope with intense affect in close personal relationships is also often fractured.
The treatment setting for a significant percentage of patients is a highly aversive environment. The clinical process necessary to modulate these patterns of response and draw the patient into an effective treatment relationship is complex and largely unexplored. The recognition that a significant percentage of patients do not do well in treatment also can provoke an intense sense of nihilism in combination with the need to contain the accounts of the patients' traumatic experience. It is not surprising that therapists who have explored and discovered new and potentially promising treatments come to advocate them with considerable enthusiasm.
Novel treatments need to be tried and further developed before they can be subjected to more rigorous scrutiny. Here a seeming collision of sentiment can occur. The scientific method involves a system of negative, rather than positive proof. The essence is to find the observation that does not confirm the hypothesis being tested, rather than to accumulate positive evidence. To some this approach can seem to be unreasonably negative.
Naturally, therapists are protective about critique of their clinical skills. Scrutiny can be unsettling. This may seem as though the purpose of research is to discredit and dismiss, rather than demonstrate the benefits of a treatment approach. Therapists may not necessarily welcome research that is less than embracing with any sense of enthusiasm and will seek to discredit the methodology rather than contemplate the possibility that the findings are valid. A tolerance of these different truths depends upon a healthy capacity to contain divergence.
A further dilemma is that the rigor of descriptive science based on statistical methodologies does not capture the essence of the humanity of suffering. Research in its most distilled form is a highly objective observation that is apolitical. Yet these data are frequently used to political ends and advocacy reasons. In the process, often data is interpreted beyond a point that is justifiable from a scientific perspective.
The strength of ISTSS depends upon the ability to recognize that the divergences within our group are less than the shared values. We should not forget that trauma still remains a very individual and in some ways isolated way of looking at psychological suffering and the human condition. We need to struggle with the unknown in our field. With increasing knowledge our ignorance can only grow. As our ignorance and uncertainty becomes more apparent, we need to accept the ambiguities, face and explore them. We need to trust the sentiments of our colleagues.
It is always easier to fight with those closest to you rather than to see the lurking and divisive skeptics who sit well beyond our midst. We should remember that the skepticism of those beyond is very different from the careful critique of those who share a passion for the same interest.
Trauma is a particular perspective of life and history. It is about advocating the nature of the reality of human experience that dissects the normal exaggeration and deception that is readily epitomized by the popular sentiments of the media. Speaking about trauma is respecting the human condition and the courage of people to exist in the powerful uncertainty of the future. We have a responsibility to document and speak for the suffering of people because we know these truths. This has major implications for the quality of the social institutions whose role it is to care for the citizens of our respective nations. ISTSS is part of this cultural matrix which aims to highlight respect for the individual and to represent the value of human suffering as a positive force in social regeneration.
During a three-month period, from April to July 1994, more than 800,000 Tutsis and 60,000 moderate Hutus were killed in Rwanda in one of the swiftest episodes of genocide and mass killing in history. It is estimated that 2.5 million Rwandans took part in these killings, which were based on a long history of intergroup conflict. Neighbors, friends, and family members turned against one another with machetes, knives, and clubs. Grenades and other explosives devastated the physical infrastructure of this tiny East Central African country the size of Maryland.
Today, the Rwandan people are trying to rebuild their communities, lives, and country. How do people recover from such massive violence and traumatization? How does a country of 8 million integrate a million refugees, Tutsis who have returned from diverse lands, speaking different languages? How do intermarried families and mixed communities renegotiate their relationships and begin to reconcile?
A small team of mental health professionals with backgrounds in violence and trauma hopes to help. Laurie Anne Pearlman, PhD, of Trauma Research, Education and Training Institute Inc. and Ervin Staub, PhD, of the University of Massachusetts-Amherst spent two weeks in Rwanda in January 1999 to lay the groundwork for an action research project titled, "Healing Through Understanding and Connection."
Along with Alexandra Gubin, BA, of the University of Massachusetts and Athanase Hagengimana, MD, of the National University of Rwanda, Pearlman and Staub have developed a plan to augment ongoing programs in Rwanda. They plan to offer staff training to members of organizations that currently work in the areas of healing, reconciliation, conflict resolution, and community building.
The goals of the training are to promote healing from traumatic stress, contribute to reconciliation, and help reduce the likelihood of further violence.
While in Rwanda, Pearlman and Staub conducted a daylong session with trainers from community organizations and trauma counselors. The 20 attendees seemed eager for more knowledge and the interconnections among organizations that the project offers. In exchange for training in seven specific areas, which Pearlman and Staub plan to conduct in Rwanda in June, the organizations will participate in research aimed at assessing the impact of current approaches and the added value of the seven elements.
The training will include psychoeducational components about the origins of genocide, basic human needs, psychological trauma, and paths to healing. Experiential elements include healing through writing and empathic responding. The training also will include a segment on vicarious traumatization in wounded healers.
Each participating organization will decide which of these elements would best augment its ongoing work. An important component of the training will be to work with participants on ways of integrating the new material into existing programs.
The John Templeton Foundation is funding this project through TREATI as part of its research program on forgiveness. The umbrella organization for the work in Rwanda is the National University of Rwanda.
Report to United Nations Alleges Violation of Women's Rights in Tibet
Investigators from the International Committee of Lawyers for Tibet and the Women's Commission for Refugee Women and Children submitted the findings of a recent fact-finding mission in a report to the United Nations in December 1998.
The mission interviewed more than 50 Tibetan women and two men who had fled Tibet, and the report evaluated whether China has complied with the Convention on the Elimination of All Forms of Discrimination Against Women. According to the report, the mission found numerous violations of the CEDAW including torture, reproductive rights, health, education, employment , and prostitution.
For more information, contact the International Committee of Lawyers for Tibet at 510/486-0588.
Trauma in Rwanda
As a result of the 1994 war and genocide in Rwanda, trauma counselors were trained to meet the urgent psychological problems in the country.
Currently, there are approximately 26 trained trauma counselors in Rwanda. In mid-1998, the Association for Trauma Counselors in Rwanda was created to handle the trauma services in the country.
For more information, contact the Association for Trauma Counselors in Rwanda at 00 25 07 85 91.
By Lynn C. Waelde, PhD
Pacific Graduate School of Psychology
Most clinical settings collect hundreds of data points on each client or patient. What are known as "data warehousing" strategies can be used to develop a rich and valuable data archive to improve treatments, inform decisions about program development, prepare annual reports of program activity, and plan and implement research.
A comprehensive data warehousing plan should address all the uses you have for archived information: clinical, legal, administrative, and research. This article offers suggestions for creating a data warehouse for research purposes from information that has already been collected, with suggestions for planning a new data warehousing system.
Creating a Data Warehouse
1. Make an honest appraisal of the data that have already been collected. Good research questions can usually be asked of data that are already available, provided that the user has confidence in the quality of the data. Questions to ask about your archive include:
- Are the measures reliable and valid for the client population?
- Are there lots of missing data?
- Are the data in a format that is easy to interpret and enter?
- Which portions of the data appear to address issues that are of research interest?
The answers to these questions may suggest the need for changes in the clinical data collection process. It may be necessary to add more measures to answer certain research questions. Consider ways to streamline the data collection process to reduce the burden on clients and therapists and reduce the expense of collecting and entering data.
2. Make a list of the data desired for warehousing and note their current location. Clinical data are stored in many forms and sometimes in many locations. Demographic and medical history may be located in the hospital chart while intake measures are stored in the therapists' filing cabinets. Some information may already be stored on computer. However, information from computerized administrations of clinical instruments typically is not transferable to other computer programs (See comments below). A careful appraisal of what data are actually needed will reduce the burden of data entry.
3. Make an appraisal of the resources you have for storing and analyzing data. Garden-variety desktop computers are more than adequate for creating a data warehouse and analyzing data for research. Statistical software packages such as SPSS will run on both Macintosh and IBM-compatible computers. The graphical user interface makes the process of entering, storing, and analyzing data simple. In addition, SPSS can import data from other formats, such as Microsoft Excel spreadsheets. Many clinical settings allow practicum students and interns to use some of the data for their own research in exchange for help in collecting and entering data.
If you have the programming and hardware resources for computerized assessments, then clients and staff can enter data directly into the computer (or onto scan sheets) for later exportation to statistical software. Some clinical settings have written their own software to computerize all the self-report measures in their assessment battery. Two major issues in the use of online assessments concern compatibility with statistical software and whether the measures have been validated for computer -- rather than paper-and-pencil -- administration.
4. Plan for the protection of human subjects. Safeguard patient confidentiality by entering identification numbers rather than names into your data warehouse. In addition, in some places the use of archival data for research requires prior subject consent, usually obtained with the consent for treatment.
The good news is that maintaining a data warehouse is easier than creating one. A carefully planned warehouse can meet the data needs of many clinical researchers and students in addition to serving important programmatic and administrative functions.
This report is sponsored by the ISTSS Special Interest Group on Research Methodology. If you are interested in becoming a member of this group, contact co-chairs Daniel and Lynda King, National Center for PTSD (116B-2), Boston VA Medical Center, 150 S. Huntington Ave., Boston, MA 02130. E-mail: firstname.lastname@example.org or lking@
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Deconstructing Psychological Debriefing and the Emergence of Calls for Evidence-Based Practice
By Anna Avery, Steve King,
Roger Bretherton and Roderick Ørner
Recent issues of ISTSS and European Society for Traumatic Stress Studies newsletters have provided a welcome opportunity for protagonists in the debriefing outcome debate to state their positions about practice and policy. It is to the credit of the field of psychotraumatology that this debate has progressed from its source, in clinical and academic disciplines, to the public domain. In this context, new and complex considerations, such as those arising from legal accountability, exert an increasing influence on the direction of the debate (Freckelton, 1998).
Under pressure to defend original theses and give account of the rationales for critical antitheses, we trust the current dialectic will prove a moderating and modernizing influence in the long term. An opportunity is being created for doctrinaire defensiveness to be replaced by tolerance of sensible pluralism and a search for common ground in published evidence.
On entering public discourse about past claims and current reappraisals, all parties in the debate share a common predicament of risking professional or personal embarrassment. The specter of costly litigation looms large.
We wonder if, at least in part, these considerations of public accountability have contributed to the shift toward more qualified claims for psychological debriefing in the fall issue of Traumatic StressPoints (Mitchell and Everly, 1998). When compared with earlier pronouncements about its apparently realizable objectives and aims (Mitchell and Everly, 1995), recent clarifications recommend themselves for recognizing the existence of an evidence base pointing to the limitations of Critical Incident Stress Debriefing. Our view is that Mitchell and Everly have presented important and timely positional statements.
As noted with surprise and interest by psychotraumatologists worldwide, it now appears Mitchell and Everly's pronouncements about the objectives and aims of CISD, made during the 1980s and as recently as 1995, should have been interpreted as pertaining exclusively to outcomes achievable by a comprehensive package of critical incident stress management services. By way of a supportive example, the authors refer to flexible, need-driven psychosocial interventions developed in a community many months after it was afflicted by natural disaster (Chemtob, Tomas, Law and Cremniter, 1997).
We wish to draw attention to a number of logical flaws in this case study approach to evidence of CISMS efficacy. For instance, claims that this systematic study confers credence on the historical, or even current, position taken by Mitchell and Everly (1998) is challenged by an examination of the list of services actually provided by Chemtob and colleagues (1997). They coordinated, to good effect, a comprehensive therapeutic program of clinical and psychosocial interventions that have but a tenuous link to practice guidelines for CISMS. Furthermore, their services hardly qualify as early interventions (Chemtob et al., 1997).
To foster a more informed view of the implications of outcome studies published to date, we would like to make the point that research reports subjected to a meta-analysis by Everly, Boyle and Lating (1998) and Everly and Boyle (1997) appear not to be a representative sample of published outcome studies. Because results derived from meta-analysis are a function of the studies included, entirely different conclusions are possible had alternative information sources been used (Davies and Crombie, 1998).
This is exactly what happened when Rose and Bisson (1999) used the Cochrane database for a different meta-analysis of other outcome studies. Any impression of bias in inclusion and exclusion criteria for meta-analyses does scant justice to the standard of scientific rigor now expected in the field of psychotraumatology. The same is true for conclusions of any one review that fails to acknowledge different outcomes reported in other publications.
Notwithstanding these obvious methodological limitations, Mitchell and Everly (1998) refer at some length to these meta-analyses that purportedly demonstrate a large positive effect attributable to the CISD intervention and the probability that such a finding might be derived by chance alone approaches zero. Not only does a study by Carlier, Lamberts, van Uchelen and Gersons (1998), which should have been acknowledged by Mitchell and Everly but was not, expose their conclusions to be statements of faith, but their declarations also belie a bizarre leap of logic. Having, with some justification, warned of methodological flaws inherent in debriefing outcome studies, these authors proceed to develop a line of reasoning premised on results of meta-analyses of exactly the type of studies they themselves consider suspect.
A further logical inconsistency warrants comment. The effect sizes purportedly revealed by the CISD meta-analyses are of a magnitude that would warrant great confidence in this particular and specific type of intervention. This leads us to wonder why Mitchell and Everly consider it necessary to argue their previous claims about achievable outcomes of early interventions pertain to a range of psychosocial interventions (CISMS) and not to any single intervention protocol. Conclusions derived from the quoted meta-analyses of group CISD, would surely justify considerable confidence in this particular intervention protocol achieving outcomes listed in their 1995 publication (Mitchell and Everly, 1995).
We see a further problem. What advice has Mitchell and Everly got for those who, in a court of law, seek a coherent rationale for the confidentiality rule applying to CISMS? Their disclaimer of specific therapeutic effect or outcome for any given intervention makes it difficult to uphold the principle of confidentiality using rationales from clinical, legal or pastoral practice. It would appear ill advised ever to have proffered this guarantee to service users.
The ESTSS has since September 1998 convened a series of European Regional Conferences On Psychological Debriefing and Early Interventions. These are part of a continent-wide consultation process involving practitioners and researchers with experience in this specialist field.
So far, evidence systematically collated in a variety of settings within the United Kingdom fails to demonstrate a distinct beneficial impact of one-off early interventions provided on a one-to-one basis (Hobbs, 1998; Brewin and Rose, 1998; Bisson, 1998). The impression formed is that the course, development and resolution of reactions to exceptionally stressful events is determined by factors, the control of which is beyond the realistic scope of early interventions.
Yet presenting opinions at a European Regional Conference is the result of a published study involving police officers in the Netherlands, some of whom underwent a CISD and some of whom did not. Evidence from follow up warns of adverse reactions that can, under certain circumstances, accrue to emergency services personnel taken through the CISD protocol by trained and experienced debriefers. (Carlier, et al., 1998)
Other speakers will have their opportunities to present original findings in a variety of European venues before the 6th European Conference on Traumatic Stress in Istanbul, Turkey, in June 1999. For this conference, a number of symposia are being convened to assess the status of evidence about early interventions and to draft guidelines on evidence-based practice.
The European Regional Conferences have so far been instrumental in engendering an appreciation that studies of CISD symptom outcome furnish, but one of a number of possible strands of evidence that should inform future practice and policy. We consider the debriefing debate remarkable for not having sought consensus about the nature of these alternative sources of evidence and the appropriate methodologies for their investigation.
In our estimation, a mistake was made in championing psychological debriefing without first generating evidence of its efficacy in terms appropriate for this type of support. The consequence of this weak evidence base is that the notion of early intervention has not been critically scrutinized. For instance, scant consideration has been given to the contradiction inherent in first stating that CISD is not a therapeutic intervention and then proffering unsubstantiated claims of its efficacy in terms drawn from clinical practice.
With such an inauspiscious start, it should come as no surprise to anyone that, true to the traditions of clinical disciplines that seek rationales for therapeutic practice through symptom outcome evaluations, priority has been given to considerations of clinical efficacy. Evidence gathered this way has not substantiated claims made for CISD. The counter-response has been to criticize systematic studies for inadequate methodological rigor. Mitchell and Every (1998) seem impervious to the monumental irony of stipulating unrealizable methodological improvements as a precondition for decisive evidence when it was the manner in which they promoted CISD in the first place that led to the adoption of these particular research methodologies.
We believe evidence in this specialist field points to a need to abandon the notion of early intervention on at least two counts. "Early" implies a time limited focus when evidence suggests informed clinical practice calls for intermediate and long-term follow up to take account of the diversity of traumatic stress reaction that come to light over time (Carlier et al. , 1998).
More significantly, we venture a view the notion of intervention shortly after exposure to traumatic stressors may be misplaced. It makes more sense to aspire to establish flexible, evidence-based support strategies developed on the basis of what victims themselves would welcome as well as the types of psychosocial support they can demonstrably put to good effect in the various stages of adjustment occurring in the wake of trauma. Outcome may more usefully be formulated in terms of facilitating improvements in the quality of the recovery environment, rather than postulates about symptomatic change, homeostatic equilibrium and identifying individuals at particular risk (Ørner, Avery and King, 1999
And finally, we have, without success, set out in search of a most elementary evidence base that confirms that emergency responders and other user groups actually want to be debriefed within the recommended 48 to 72 hours of a critical event. If this evidence base is as weak as we suspect, it would appear there is no valid rationale for advocating this specific type of early intervention. Given that Mitchell and Everly took the lead in recommending CISD during the 1980s, it may help raise the standard of the debriefing debate if they were to explain the evidence-based rationales for publicly advocating early intervention in general, and then give account of how this evidence base in turn gave rise to designated protocols for delivering CISD and other CISMS.
Bisson, J.I. (1997) Is post-traumatic stress disorder preventable? Journal of Mental Health 6, 2, 109-111
Brewin, C.R., Andrews, B. & Rose, S. (1999) A Preventative Programme for Victims of Violent Crime. In press
Carlier, I.V.E., Lamberts, R.G., van Uchelen, A.J. & Gersons, B.P.R. (1998). Disaster related post-traumatic stress in Police Officers: A field study of the impact of debriefing. Stress Medicine, 14, 143-148
Chemtob, C., Tomas, S., Law, W. & Cremniter, D. (1997) Postdisaster psychological intervention: A field study of debriefing on psychological distress. American J Psychiatry 154, 415-417
Davies, H.T.O. & Crombie, I.K. (1998) Getting to grips with systematic reviews and meta-analyses. Hospital Medicine 59, 12, 955-958
Everly, G.S. & Boyle, S. (1997) Critical Incident Stress Debriefing (CISD): A meta analysis. Paper Presented at the Fourth World Congress on Stress, Trauma and Coping in the Emergency Services Professions, Baltimore, MD, USA.
Everly, G.S., Boyle, S., & Lating, J. (1998) Psychological debriefing: A Meta Analysis. Paper presented at First Nations' Emergency Services Society Critical Incident Stress Conference, Vancouver, BC, Canada.
Freckleton, I. (1998) Critical Incident Stress Intervention and the Law. Journal of Law and Medicine. November 1998
Hobbs, M., Mayou, R., Harrison, B. & Worlock, P. (1996) Randomized controlled trial of psychological debriefing for victims of road traffic accidents. British Medical Journal 313, 1438-1439
Mitchell, J.T. & Everly, G.S. (1995) Critical Incident Stress Debriefing (CISD); and the prevention of work related traumatic stress among high risk occupational groups. In G.S. Everly and J.M. Lating (Eds.), Psychotraumatology: Key Papers and Core Concepts in Post Traumatic Stress (PP 267-280. New York: Plenum Press.
Mitchell, J.T. & Everly, G.S. (1998) Critical Incident Stress Management: A New Era in Crisis Intervention. Traumatic StressPoints, Fall 1998, 6-11
Ørner, R.J., Avery, A. & King, S. (1999). An evidence based rationale for early intervention after critical incidents. Paper presented at European Regional Conferences on Early Interventions and Psychological Debriefing, Aberdeen, Scotland.Raphael, B., Meldrum, L. & McFarlane, A.C. (1995) Does debriefing after psychological trauma work ? Time for randomised controlled trials. British Medical Journal, 310, 1479-1480
Rose, S. & Bisson J.I. (1999) One-off psychological interventions following trauma: A systematic review of the literature. Journal of Traumatic Stress (in press)
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American Journalism Review Recognizes Vicarious Traumatization in Journalists
By Frank M. Ochberg, MD
Contributing editor,, media
Reporting in the January/February 1999 issue of the American Journalism Review, Sherry Ricchiardi finds, "Covering tragedy can create immense psychological stress for journalists. Sometimes it makes sense to get help."
Interviews with a dozen media professionals who witnessed crime scenes, battle deaths, and autopsy photographs reveal a willingness to admit symptoms of primary and secondary traumatic stress disorder. However, the newsroom culture remains stoic and open discussion of emotional distress is rare.
"For those in the news gathering business, seeking professional help can be perilous ... It may even spark editors to pull them off important projects or move them to softer assignments," writes Ricchiardi.
This reminds me of the situation in police departments and public schools 20 years ago. Little was said on the job after a suicide, disaster, or any unexpected tragedy. Now every school has a plan for posttraumatic counseling and law enforcement agencies have manditory stress evaluations after certain shooting incidents. But this took time, enlightened leadership, and self-awareness.
Obviously, a clash of values and traditions can have demoralizing effects upon a workplace. Media organizations are changing dramatically in size, shape, and demographics. Fifty years ago there were no women in British journalism and few in America or Australia. Now the gender ratio of new hires is 50-50. Many editors of large papers and news directors of large TV stations welcome mental health counsel, but middle management often retains the traditional macho orientation.
To consider these issues with ISTSS members, Ricchiardi and two distinguished sources for her article will attend the ISTSS 15th Annual Conference in November. Chris Cramer is the international news director of CNN. When he worked for the BBC, he was held hostage during an embassy siege. Rick Bragg won a Pulitzer Prize as a war correspondent for The New York Times. Neither wants to discuss personal issues, but both want to help define a research agenda that ultimately will benefit the traumatized journalist. Times, they are a changin'.
By Brian Engdahl, PhD
VA Medical Center, Minneapolis
International Handbook of Multigenerational Legacies of Trauma. Yael Danieli (Ed.) New York: Plenum Press, 1998, 710 pages. Hardbound. $95.
Chronic posttraumatic stress disorder and related psychopathology not only affect many trauma survivors for decades, but also might affect their offspring, substantially increasing the public health impact of trauma. Many professionals study and treat those who experience the intergenerational effects of trauma exposure, a fact convincingly demonstrated by this book.
Its breadth of coverage is impressive. Contributions have been pulled together from virtually every part of the world. They describe multigenerational effects stemming from many trauma sources, among them the Holocaust, genocide in Cambodia and Armenia, World War II and the Vietnam War, repressive regimes, domestic violence and crime, and life-threatening diseases. Intergenerational effects revealed after the fall of communism -- central to which are issues of submerged ethnic identity -- are given considerable attention within this volume.
The book brings less familiar populations of concern into focus, many for the first time in print, including offspring of the Nazis and their collaborators, Japanese atomic bomb survivors, Australian Aboriginal people, breast cancer patients, Stalin's purge victims, Nigerian civil war survivors, American Indians, and Baha'i martyrs in Iran.
The contributions understandably vary widely in their levels of presentation. Where work is in an early stage, e.g., among Japanese atomic bomb survivors, a chapter may be centered on a clinical vignette. Where more research has been conducted, e.g., in the area of domestic violence, models supported by data are presented. Danieli provides a unifying intervention-oriented framework that helps readers conceptualize the domain of multigenerational trauma. The framework, coupled with her chapter editing, creates coherence seldom found in edited volumes.
The ways in which trauma may effect subsequent generations (the mode of transmission question) is addressed from multiple perspectives throughout the book. Psychodynamic, family systems, genetic, and socio-cultural perspectives are presented. In a unique chapter, Suomi and Levine review animal studies and suggest at least three routes through which parents' trauma exposure may have effects on offspring: observational learning, parental behaviors, and prenatal effects.
Data drawn from several populations show that offspring of negatively affected trauma survivors are themselves less well adjusted. The chapter by Yehuda and colleagues -- an overview of their biologically oriented work with Holocaust survivors and their offspring -- most clearly demonstrates this. This chapter (and more recent work in the field) does not elucidate the modes of transmission. Instead it makes it clear that having a parent with PTSD has direct effects on one's adjustment and may be a risk factor for the development of the disorder in response to one's own traumatic experiences.
Previous books have been limited to coverage of only one survivor-offspring group, and typically have used a single theoretical perspective. In that it describes many groups from multiple perspectives, the International Handbook of Multigenerational Legacies of Trauma is the first volume of its kind. At the same time, it is no preliminary attempt. The book is truly a great leap forward and crammed with implications for survivors and their families, clinicians, researchers, and policymakers. It defines this domain within traumatic stress studies, and will be a standard reference for years to come.
Compiled by Elana Newman
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Andrykowski, M A.; Cordova, M J.; Studts, J L.; Miller, T W (1998). Posttraumatic stress disorder after treatment for breast cancer: Prevalence of diagnosis and use of the PTSD Checklist--Civilian Version (PCL--C) as a screening instrument. Journal of Consulting & Clinical Psychology, 66 58659.
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Servan-Schreiber, D., Le Lin, B., & Birmaher, B. (1998). Prevelance of Posttraumatic Stress Disorder and major depressive disorder in Tibetian refugee children. Journal of the American Academy of Child and Adolescence, 37, 874879.
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UC San Francisco
Trauma Treatment Program
The Department of Psychiatry of the School of Medicine, University of California, San Francisco (UCSF) is seeking a Psychiatrist for the Trauma Treatment Program of the Psychosocial Medicine Clinic at San Francisco General Hospital, a major teaching hospital of UCSF. The position offers an exciting opportunity to help develop trauma-focused outpatient psychological services at SFGH and the San Francisco Community Health Network. Duties include providing direct clinical services to a wide variety of patients, including individuals with a history of chronic physical and sexual abuse, victims of violence, including sexual assaults, domestic violence, survivors of political torture, refugee groups, and patients recovering from severe physical trauma. The majority of these patients are medically indigent and typically have concurrent medical, psychosocial, and substance abuse problems. Other duties include: consultation with primary-care providers and liaison with community-based agencies; psychopharmacological evaluations and medication support services; supervision of psychology and social work interns, and psychiatry residents; and in-service training of staff. The ideal candidate must possess a minimum of two years' experience and expertise providing trauma-focused treatment, strong enthusiasm and ability to work collaboratively with a multidisciplinary team, excellent teaching and supervisory skills, and demonstrated competency in working with culturally diverse, low-income and medically indigent patient populations. Experience working in a hospital setting, with patient with severe psychosocial problems and/or substance abuse problems is desirable. Bilingual applicants are strongly encouraged to apply. Please send a letter of interest, resume, and names, addresses, and telephone numbers of three references to:
Vanessa Kelly, PhD
Psychosocial Medicine Outpatient Clinic
Department of Psychiatry-Suite 7M
San Francisco General Hospital
1001 Potrero Ave.
San Francisco, CA 94110
For further information regarding the position you may contact Kelly
at 415/206-4967. UCSF is an equal opportunity/affirmative action employer.
The university undertakes affirmative action to ensure equal employment opportunity for underutilized minorities and women, persons with disabilities, and Vietnam-era veterans and disabled veterans.
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