Assessing and Treating Posttraumatic Stress Disorder: An Update

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From antiquity, physicians have encountered the consequences of violence in their many clinical presentations. Even today, whether as primary care physicians, gynecologists, pediatricians, surgeons, or psychiatrists, clinicians encounter the myriad faces of trauma. Since World War I (Salmon, 1917), we psychiatrists and mental health colleagues have pioneered a new venture in medicine: assessing and healing the mental, emotional, and behavioral sequelae of trauma. Our basic understanding regarding the effects of trauma owes much to colleagues in other fields, from Emil Durkheim's sociopsychological studies of suicide in 1880s France (Durkheim, 1951), to Ruth Benedict's 1940s analysis of cultural struggles leading to Pearl Harbor—widely read and influential in post–World War II Japan (Benedict, 1989). Author-observers of the human condition have left us timeless insights regarding our violent propensities, from Lord Buddha—a feudal prince trained in military arts (Johnson and Westermeyer, 2000), to Homer's Iliad detailing Achilles' response to his friend's death at Troy (Shay, 1991), to Crane's “Red Badge of Courage” tracing the trajectory of a young soldier's trials at overcoming combat panic during the Civil War (Crane, 1895). These five reports continue this enduring effort to contain traumatic morbidity.
This universality of violence among our kind calls for a species-based, worldwide approach to the topic. The investigations in this JNMD issue reflect this strategy, originating from violent events on three continents (Africa, Europe, and North American) and delayed psychiatric disorders in two refugee resettlement countries (Denmark and Switzerland). A range of institutions supported these studies: medical centers, research institutes, universities and their departments, and the World Health Organization. These articles reveal the breadth of traumatic events and their potential to harm that vital organ of awareness, learning, understanding, and adaptation.
Two articles involve case studies of trauma instigated by humans on humans. The first, from Rwanda, was experienced as a nationwide, government-led genocide perpetrated by transforming ethnic discord into mass murder. The second, a report from North America, centers on male-on-female rape violence. Such genres of interpersonal violence threaten trust within the human family, upon whom we all depend. The common element in rape and genocide lies in their assault on a central tenant of our species' survival, which requires that we trust our community. Both studies depict children and woman as the special victims of genocide and rape when this trust is broken.
The report from Turkey, an international leader in trauma studies, focuses on a natural disaster. Our planet produces violence of this kind, albeit in different geographical shapes, leaving no region untouched. Earthquakes, floods, storms, winds, forest fires, drought, volcanoes, and other planetary disruptions undermine our reliance on an ordinarily predictable and nurturing mother earth. A common dilemma in these disasters involves the decision 1) to remain or return to original domiciles versus 2) to flee and relocate. The Turkish study concentrates on return to the original home, discovering that greater subsequent distress afflicted returnees to areas of greater destruction. This finding reveals the complex nature of resettlement decisions, while also potentially informing public policy decisions following disasters.
These five reports signal the expanding use of diverse data-collecting methods in the trauma field. Early on, symptom measurement—using rating scales—comprised the primary instruments. These five publications employ additional methods, including geometric data collection, predicting future morbidity, applying psychophysiological instrumentation, and creatively reanalyzing older data sets informed by new understanding and evolving theory.
Both projects on traumatized children addressed topics unique to children: child developmental phases as a factor in future symptoms and associations between childhood trauma and early adult psychiatric disorder. The Rwandan study revealed less severe symptoms among traumatized children compared with traumatized adolescents.
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