The role of proximity, immediacy, and expectancy in frontline treatment of combat stress reaction among Israelis in the Lebanon War

Life and mental health in limbo of the Ukraine war: How can helpers assist civilians, asylum seekers and refugees affected by the war?

The terror spread by the war disrupts lives and severs families, leaving individuals and communities devastated. People are left to fend for themselves on multiple levels, especially psychologically. It is well documented that war adversely affects non-combatant civilians, both physically and psychologically. However, how the war puts civilians' lives in a limbo is an under-researched area. This paper focuses on three aspects: (1) how the mental health and well-being of Ukrainian civilians, asylum seekers, and refugees are affected by the war caused limbo; (2) what factors affect this process of being stuck in the limbo of war; and (3) how psychologists and helpers in the war-ridden and host countries can provide meaningful support. Based on the authors' own practical work with Ukrainian civilians, refugees, and professional helpers during the war, this paper provides an overview of multi-level factors that impact human psyches in a war, and possible ways to help those who are living in the war limbo. In this research and experiential learning-based review, we offer some helpful strategies, action plans, and resources for the helpers including psychologists, counselors, volunteers, and relief workers. We emphasize that the effects of war are neither linear nor equal for all civilians and refugees. Some will recover and return to a routine life while others will experience panic attacks, trauma, depression, and even PTSD, which can also surface much later and can prolong over the years. Hence, we provide experience-based ways of dealing with short-term and prolonged trauma of living with war and post-traumatic stress disorder (PTSD). Mental health professionals and other helpers in Ukraine and in host countries can use these helping strategies and resources to provide effective support for Ukrainians and for war refugees in general.

Breaking down barriers to help-seeking: preparing first responders' families for psychological first aid

BACKGROUND

First responders regularly encounter both operational stressors and potentially traumatic events, increasing their risk of mental health issues (Declercq et al., 2011). Due to unique cultural complexities, they turn mostly to peers for early psychosocial support (Isaac & Buchanan, 2021). However, peer support and/or mental health assistance may not always be available or easy to access and first responders' mental health suffers.

OBJECTIVE

We need more accessible routes to crisis intervention to ensure first responder resilience and wellbeing, so they may continue to function in the service of public safety. Family members and close friends may be ideally placed to provide this immediate care. This article outlines the protective role of social support as an early intervention strategy to mitigate the effects of first responder trauma, exploring the potential opportunity for family members and friends to play an increasingly supportive role in their loved one's wellbeing. This paper serves as a call to action for practical educational interventions that will prepare family members for these critical conversations.

CONCLUSION

We see potential in combining early intervention theory, psychoeducation, and a strengths-based gender specific positive psychology approach. Further study should investigate how best to help first responders break down barriers to support, by bolstering their existing social supports and ultimately reducing the stigma associated with experiencing traumatic stress.

HIGHLIGHTS

By training family members in psychological first aid, we may strengthen existing social support for first responders, providing more options for, and potentially breaking down stigma associated with help-seeking.

Continuum of care for disasters and catastrophes

Disasters and their more extensive and more serious variant, catastrophes, are different than most human experiences. They are inherently quite complex. Extensive and diverse resources are required to assist disaster survivors as well as disaster response personnel, and hospital medical staffs. Except for warfare, there are few other human predicaments that require such a massive and highly coordinated response. Traditional psycho-therapeutic interventions have little chance of being helpful in the acute stages of a disaster. Research demonstrates that selected crisis intervention processes provided by crisis-trained psychological support personnel have been quite successful in assisting both the survivors and responders in coping with disasters and catastrophes. Assistance to military personnel, emergency operations personnel, and survivors must be carefully crafted to assure that the right type of help is provided at the right time by the most appropriate, well-trained, and experienced personnel. This paper employed a scoping review methodology synthesizing the lessons gleaned from wars and past disasters beginning in the late 1800's up to the present. It sets a course for the appropriate management of the psychological impacts of future disasters and catastrophes. Evidence suggests effective psychiatric and psychological services provided during and in the aftermath of a disaster must be simple, brief, immediate, practical, and innovative. Most importantly, disaster mental health support services must consist of an integrated and comprehensive continuum of mental health services spanning all levels of intensity of support and care.

Examining the development of PTSD symptoms in individuals who witness acute stress reaction on the battlefield

Adler et al describe an innovative perspective on battlefield posttraumatic stress disorder (PTSD) symptoms in response to an acute stress reaction (ASR), tracking not the individual experiencing ASR, but rather the service members who witness another team member experiencing an ASR. PTSD symptoms, reactions, observations and responses in the witness are assessed.

Psychosocial support for providers working high-risk exposure settings during a pandemic: A critical discussion

Psychological first aid is a form of support designed to lessen disaster‐related distress. In a pandemic, providers may need such support but with the high risk of exposure, such a program is offered only virtually. The research is scant for traditional post‐disaster support and non‐existent for virtual; therefore, by using related research this discussion considers the likelihood of providers accessing and benefiting from this program. The virtual platform is heralded as the responsible way to provide support in a pandemic but this standard may be ineffective and is inherently inequitable. As a global event, pandemics require containment strategies applicable on an international level; therefore, psychosocial support should also be developed with an international audience in mind. Online psychosocial support falls short of being such a strategy as it incorrectly assumes global internet access. Many low‐income areas such as Sub‐Saharan Africa will need support strategies which compliment local frontline staff and fit with community‐driven initiatives, whereas wealthier countries may use a combination of onsite and online support. Provider psychosocial support needs in a pandemic, if articulated, are globally similar but how this support is offered requires contextually sensitive considerations not yet found in the literature.

Psychological first aid to support healthcare professionals

Psychological first aid (PFA) may be considered a form of acute psychological crisis intervention designed to foster human resilience. PFA has been universally endorsed as an important addition to the corpus of mental health-related support services in the wake of disasters. As support grows for its utilization beyond disasters alone, consideration should be given to the application of PFA to high-risk occupational setting. While PFA has begun to be used in the emergency services, it would also seem to be well suited for fostering resilience in healthcare settings where burnout and vicarious traumatization may approach the prevalence of silent epidemics. This paper describes PFA and argues for its utilization as a non-stigmatizing approach to foster the resilience of healthcare professionals and in doing so avoiding the “second victim” phenomenon.

From the Frontline to the Homefront: The Experience of Israeli Veterans

In 1948, the state of Israel was created as a homeland for the Jewish people after 2,000 years of persecution and deportations in the diaspora. During the past 72 years, its inhabitants have experienced several wars and numerous terrorist attacks. Therefore, the issue of trauma goes beyond academic study, it is part of daily life. These circumstances have, unfortunately, turned Israel into a natural stress laboratory, which has enabled the systematic research of the biopsychosocial effects of traumatic stress on soldiers and civilians. This article reviews the findings of a series of studies that examine (a) the short- and long-term mental health effects of war on combat veterans; (b) the effects of repeated exposure to war on veterans; (c) trajectories of PTSD; and, specifically, (d) reactivation and (e) delayed-onset PTSD. We present the findings of two decades of systematic trauma research, which have followed the ongoing psychopathological effect of war on veterans. In understanding the ripple effects of trauma, it can be seen that veterans do not leave the events of the war behind once they are home; rather, it is with them wherever they go. Consequently, the trauma has a ripple effect that may carry over to veterans' spouses and offspring. The multiple manifestations and trajectories of both acute and chronic trauma will be presented. Clinical ramifications and implications will also be discussed.

When helpers need help: A case study on the 2012 earthquakes in Italy

BACKGROUND

After two strong earthquakes in the Emilia region in Italy, many HCWs had to deal with the psychological consequences of the aftershocks.

OBJECTIVE

The aims of this case study were a) to describe the psychosocial condition of the HCWs affected by the earthquake; b) to present an intervention immediately after the earthquake on HCWs in a post-disaster situation using a mixed-method approach.

METHODS

A mixed-method study was conducted collecting qualitative data (during Group Counselling sessions) and quantitative data (through questionnaires).

RESULTS

The results suggested that the impact of the earthquake was very strong, as more than 80% perceived at least a severe impact event capable of altering their ability to function; most of the thoughts and feelings were related to death and fear.

CONCLUSIONS

This study adds knowledge about how to plan interventions aiming to help those workers at both individual and organisational level.

Integrating occupational therapy in treating combat stress reaction within a military unit: An intervention model

Combat stress reaction (CR) is a syndrome with a wide range of symptoms including changes in soldiers' behaviors, emotional and physiological responses, avoidance and a decrease in both personal and military functioning. The short-term goal in treating CR is a speedy return to healthy functioning, whereas the long-term goal is to prevent the development of PTSD. Previous research has indicated that the achievement of this short-term goal affects the achievement of the long-term goal and vice versa. Effective treatment requires intervention by trained professionals proficient in reinforcing personal and functional identity without psychiatric labelling. The present paper presents a therapeutic model integrating OT in treating CR within a military setting. The model emphasizes the importance of preventing fixation to the role of 'patient' and a rapid return to maximal functioning. Based on Kielhofner's Model of Human Occupation, which aims to promote adaptive and efficient functioning by engaging soldiers in tasks supporting their military identity, empowering functionality, and increasing their perceived competency. The model emphasizes the therapeutic milieu within a military environment. Practical application of this model focuses on interdisciplinary aspects and client-focused application. The paper describes an assessment process for each soldier entering the CR unit and a treatment model integrating OT.

Trauma, crisis intervention and psychological debriefing

Fifty percent of those involved in catastrophic events will be sufficiently affected to need professional help. The trauma experienced is not simply a set of symptoms (Post Traumatic Stress Disorder), but a major change in the person's "assumptive world", the way the self and the world around it is understood.

Crisis intervention must focus on allowing victims to psychologically "process" the events and their reactions by assisting them to build frame works of understanding within which their shattered assumptions and new perceptions of themselves may be ordered.

Psychological debriefing is put forward as a model of crisis intervention which facilitates this process. A "Debriefing Continuum" is identified in which three types of debriefing; group, large group, and individual may be placed and contrasted. A sequence of intervention is proposed.

Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?

In the wake of the terrorist attacks at the World Trade Center, more than 9,000 counselors went to New York City to offer aid to rescue workers, families, and direct victims of the violence of September 11, 2001. These mental health professionals assumed that many New Yorkers were at high risk for developing posttraumatic stress disorder (PTSD), and they hoped that their interventions would mitigate psychological distress and prevent the emergence of this syndrome. Typically developing in response to horrific, life-threatening events, such as combat, rape, and earthquakes, PTSD is characterized by reexperiencing symptoms (e.g., intrusive recollections of the trauma, nightmares), emotional numbing and avoidance of reminders of the trauma, and hyperarousal (e.g., exaggerated startle, difficulty sleeping). People vary widely in their vulnerability for developing PTSD in the wake of trauma. For example, higher cognitive ability and strong social support buffer people against PTSD, whereas a family or personal history of emotional disorder heightens risk, as does negative appraisal of one's stress reactions (e.g., as a sign of personal weakness) and dissociation during the trauma (e.g., feeling unreal or experiencing time slowing down). However, the vast majority of trauma survivors recover from initial posttrauma reactions without professional help. Accordingly, the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery. The need for controlled evaluations of early interventions has only recently been widely acknowledged.

Psychological debriefing—the most widely used method—has undergone increasing empirical scrutiny, and the results have been disappointing. Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma.

Recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. Providing information about the trauma and its consequences is also important. However, research evaluating the efficacy of such “psychological first aid” is needed.

Some researchers have developed early interventions to treat individuals who are already showing marked stress symptoms, and have tested methods of identifying those at risk for chronic PTSD. The single most important indicator of subsequent risk for chronic PTSD appears to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (provided that the event is over and that there is no ongoing threat).

Cognitive-behavioral treatments differ from crisis intervention (e.g., debriefing) in that they are delivered weeks or months after the trauma, and therefore constitute a form of psychotherapy, not immediate emotional first aid. Several controlled trials suggest that certain cognitive-behavioral therapy methods may reduce the incidence of PTSD among people exposed to traumatic events. These methods are more effective than either supportive counseling or no intervention.

In this monograph, we review risk factors for PTSD, research on psychological debriefing, recent recommendations for crisis intervention and the identification of individuals at risk of chronic PTSD, and research on early interventions based on cognitive-behavioral therapy. We close by placing the controversy regarding early aid for trauma survivors in its social, political, and economic context.

Moral dilemmas faced by hospitals in time of war: the Rambam Medical Center during the second Lebanon war

Rambam Medical Center, the only tertiary care center and largest hospital in northern Israel, was subjected to continuous rocket attacks in 2006. This extreme situation posed serious and unprecedented ethical dilemmas to the hospital management. An ambiguous situation arose that required routine patient care in a tertiary modern hospital together with implementation of emergency measures while under direct fire. The physicians responsible for hospital management at that time share some of the moral dilemmas faced, the policy they chose to follow, and offer a retrospective critical reflection in this paper. The hospital's first priority was defined as delivery of emergency surgical and medical services to the wounded from the battlefields and home front, while concomitantly providing the civilian population with all elective medical and surgical services. The need for acute medical service was even more apparent as the situation of conflict led to closure of many ambulatory clinics, while urgent or planned medical care such as open heart surgery and chemotherapy continued. The hospital management took actions to minimize risks to patients, staff, and visitors during the ongoing attacks. Wards were relocated to unused underground spaces and corridors. However due to the shortage of shielded spaces, not all wards and patients could be relocated to safer areas. Modern warfare will most likely continue to involve civilian populations and institutes, blurring the division between peaceful high-tech medicine and the rough battlefront. Hospitals in high war-risk areas must be prepared to function and deliver treatment while under fire or facing similar threats.

Incidence and predictors of acute psychological distress and dissociation after motor vehicle collision: a cross-sectional study

OBJECTIVE

We examined the incidence and predictors of peritraumatic distress and dissociation after one of the most common forms of civilian trauma exposure: motor vehicle collision (MVC).

METHOD

In this study, patients presenting to the emergency department after MVCs who were without serious injury and discharged to home after evaluation (n = 935) completed an emergency department interview evaluating sociodemographic, collision-related, and psychological characteristics.

RESULTS

The incidence and predictors of distress (Peritraumatic Distress Inventory score ≥23) and dissociation (Michigan Critical Events Perception Scale score >3) were assessed. Distress was present in 355 of 935 patients (38%), and dissociation was present in 260 of 942 patients (28%). These outcomes showed only moderate correlation (r = .45) and had both shared and distinct predictors. Female gender, anxiety symptoms prior to the MVC, and vehicle damage severity predicted both distress and dissociation. Higher socioeconomic status (higher education, higher income, full-time employment) had a protective effect against distress but not dissociative symptoms. Better physical health and worse overall mental health were associated with increased risk of dissociation but not distress. Distress but not dissociation was associated with lower patient confidence in recovery and a longer expected duration of recovery.

CONCLUSION

There are unique predictors of peritraumatic distress and dissociation. Further work is needed to better understand the neurobiology of peritraumatic distress and dissociation and the influence of these peritraumatic outcomes on persistent psychological sequelae.

Rear Operations Group medicine: a pilot study of psychological decompression in a Rear Operations Group during Operation HERRICK 14

OBJECTIVES

To investigate group activity psychological decompression (GAPD) in a Rear Operations Group.

METHODS

Provision of military archaeological exercises for a Rear Operations Group's medical centre patients during Op HERRICK 14 with analysis of before and after Patient Health Questionnaires (PHQ), Work and Social Adjustment Scales, generalised anxiety disorder (GAD) 7 Anxiety, Audit Questionnaire and Impact of Events Scale Revised and analysis of interviews with supervisors and soldiers.

RESULTS

Soldiers reported a mean of 13%-38% improvement across the self-reported domains. The civilian archaeologists reported improvements in self-esteem, morale and team-working. 10 out of 24 soldiers have expressed an interest to pursue archaeology further; eight soldiers disclosed mental health issues for the first time, four of whom required mental health referral.

CONCLUSIONS

GAPD can help early-returned soldiers in reducing symptoms of anxiety, depression, isolation and psychological traumatic symptoms. It also helps to increase perception of their ability to work and socialise as a team and help them to an early return to work. It can provide soldiers with the opportunity to approach their supervisors in an informal manner and help in early detection of mental health problems.

The Traumatic Process: Conceptualization and Treatment

Traumatic stress stems from a threat to an individual's or a group's very existence. The impact of the existential threat may be compounded by an inability to cope, which affects the perception of helplessness and loss of lawfulness. A model is proposed in which the traumatic process is conceptualized to develop through three stages: (1) alert; (2) impact; and (3) post-trauma. In this model, treatment of traumatic stress emphasizes the need to control and expand life, and to achieve lawfulness and meaningfulness. In the proposed model of treatment, there are essential differences at each of the stages of the traumatic process: (1) primary prevention at the stage of alert focuses on planning strategies for coping; (2) secondary prevention at the stage of impact is based on forward treatment and debriefing; and (3) tertiary treatment at the post-trauma stage attends to coping with internal chaos and arbitrariness.

Long-term military work outcomes in soldiers who become mental health casualties when deployed on operations

BACKGROUND

little is known about longer term military work outcomes in UK military personnel who develop mental health problems when operationally deployed. Deployed Field Mental Health Teams (FMHTs) who support them follow the principles of "Forward Psychiatry," aiming to treat psychiatric casualties close to the front line to maximize operational effectiveness and occupational retention.

AIM

to examine the short- and long-term military work outcomes in soldiers deployed to Iraq between 2003 and 2007 who were referred to the FMHT.

METHOD

FMHT clinical records were linked to occupational records with 825 resulting matches.

RESULTS

71.6% of the referred soldiers with a documented short-term military work outcome returned to their operational unit, and 73.5% of those who had a documented long-term military work outcome served on for a period in excess of two years. Adjusting for potential confounders, a shorter service length and removal from the operational theatre were both strongly associated with premature discharge; however, it was not possible to determine the severity of the presenting mental health problem and assess whether this impacted outcome.

CONCLUSIONS

the results of this study support the use of the Forward Psychiatry principles in achieving good short-term military work outcomes. Utilizing these principles, three-quarters of those referred to the FMHT were returned to their deployed unit and approximately three-quarters of those assessed by the FMHT remained in service two years after referral. We suggest that these are positive work outcomes; however, being evacuated out of the operational environment and having a short service length were both associated with premature discharge, though we were unable to examine the role of illness severity.

Does one size fit all? The challenges of establishing a coordinating center for research of post-disaster needs assessment

Needs assessment in the wake of disasters is most significant yet highly complex and challenging. Kessler et al. propose a comprehensive disaster mental health research model. This model has several significant advantages: (1) Pre-prepared plans and resources allow rapid deployment of skilled professionals; (2) Continuity will ensure that lessons learned from one disaster will be retained and used in subsequent disasters; (3) Standardization will provide a solid basis for evaluation and comparison across events; (4) Continuous monitoring of needs over time will enable the capture of a full range of responses including delayed effects; and (5) Will provide a valuable resource for researchers in the field. At the same time, there are a number of challenges that must be considered before the establishment and implementation of the proposed center and use of standardized measures. These challenges are associated with the observation that different disasters give rise to different problems and needs; there is considerable cultural variability; and differential power and agenda of stakeholders may result in a limiting 'tunnel vision' approach that may undermine new developments, creativity, and progress. Ways to overcome these challenges and difficulties that are involved in the implementation of such a model are suggested.

An Evaluation of a Police Debriefing Programme: Outcomes for Police Officers Five Years after a Police Shooting

To evaluate the effectiveness of a debriefing programme to reduce traumatic stress in a police organisation, officers involved in a shooting were surveyed by questionnaire, five years after the event. The results showed that 79 per cent of 57 officers had not received debriefing, despite its mandatory status. Those who had received debriefing had higher post-traumatic stress disorder (PTSD) scores; however, regression of PTSD and health scores, on stress perceptions, social support, other trauma, and debriefing, showed that debriefing had no significant effect. These results support those of other controlled studies suggesting that debriefing does not mitigate PTSD and may exacerbate symptoms. A number of limitations of the present study are discussed in terms of suggestions for urgent evaluation of such programs in organisational settings.

War & military mental health: the US psychiatric response in the 20th century

Involvement in warfare can have dramatic consequences for the mental health and well-being of military personnel. During the 20th century, US military psychiatrists tried to deal with these consequences while contributing to the military goal of preserving manpower and reducing the debilitating impact of psychiatric syndromes by implementing screening programs to detect factors that predispose individuals to mental disorders, providing early intervention strategies for acute war-related syndromes, and treating long-term psychiatric disability after deployment. The success of screening has proven disappointing, the effects of treatment near the front lines are unclear, and the results of treatment for chronic postwar syndromes are mixed. After the Persian Gulf War, a number of military physicians made innovative proposals for a population-based approach, anchored in primary care instead of specialty-based care. This approach appears to hold the most promise for the future.

Historical approaches to post-combat disorders

Almost every major war in the last century involving western nations has seen combatants diagnosed with a form of post-combat disorder. Some took a psychological form (exhaustion, combat fatigue, combat stress reaction and post-traumatic stress disorder), while others were characterized by medically unexplained symptoms (soldier's heart, effort syndrome, shell shock, non-ulcer dyspepsia, effects of Agent Orange and Gulf War Syndrome). Although many of these disorders have common symptoms, the explanations attached to them showed considerable diversity often reflected in the labels themselves. These causal hypotheses ranged from the effects of climate, compressive forces released by shell explosions, side effects of vaccinations, changes in diet, toxic effects of organophosphates, oil-well fires or depleted-uranium munitions. Military history suggests that these disorders, which coexisted in the civilian population, reflected popular health fears and emerged in the gaps left by the advance of medical science. While the current Iraq conflict has yet to produce a syndrome typified by medically unexplained symptoms, it is unlikely that we have seen the last of post-combat disorders as past experience suggests that they have the capacity to catch both military planners and doctors by surprise.

Behavioral health care of isolated military personnel by videoconference

The changing role of the military presents a unique challenge for military behavioral health organizations in dealing with the geographic isolation of personnel. Telemedical solutions should help to meet this challenge. In the behavioral health arena, there are many uses for videoconferencing and other communications technology in maintaining continuity when patients or clinicians travel or deploy; assisting isolated behavioral health-care providers and general practitioners; evaluating and treating isolated military personnel; and addressing family issues. Family interventions by videoconference and other communications technology may be particularly useful in treating military personnel and in promoting morale of the fighting force. Although much remains to be researched and proven empirically, anecdotal experience supports the utility of using communications technology to enhance behavioral health interventions. This article describes the clinical videoconference experience within the Department of Psychiatry at Tripler Army Medical Center (TAMC), during a Multinational force deployment to the Sinai, and during training at the Joint Readiness Training Center, Fort Polk, Louisiana. A brief discussion of potential legal issues involving videoconferencing in behavioral health is also included.

"Forward psychiatry" in the military: its origins and effectiveness

"Forward psychiatry" was devised in World War I for the treatment of shell shock and today is the standard intervention for combat stress reaction. It relied on three principles: proximity to battle, immediacy, and expectation of recovery, subsequently given the acronym "PIE." Both US and UK forces belatedly reintroduced PIE methods during World War II to return servicemen to active duty and made confident claims for its efficacy. Advanced treatment units also appeared to have minimized psychiatric battle casualties during Korean and Vietnamese Wars. Evaluations of its use by Israeli forces in the Lebanon conflict showed higher return-to-duty rates than at base hospitals. A reexamination of these examples suggests that reported outcomes tended to exaggerate its effectiveness both as a treatment for acute stress reaction and as a prophylaxis for chronic disorders such as PTSD. It remains uncertain who is being served by the intervention: whether it is the individual soldier or the needs of the military.

Psychosocial response to disaster: the attacks on the Stark and the Cole

The terrorist attack on the USS Cole on 12 October 2000 was remarkably similar to the 1987 attack on the USS Stark. This article discusses the psychosocial consequences of the attacks on the families and crews of the ships and the community response of the Navy to the attacks, particularly that of the Navy Family Service Centers. The impact of the attacks is compared to the impact of natural and man-made disasters on communities while the impact on the crew is examined in light of combat psychiatry and post-traumatic stress disorder (PTSD). Events such as these are very likely to produce PTSD despite early intervention efforts. Following the attack on the Stark greater attention was given to the grief of family members than to the trauma of the crew, while the crew of the Cole has received longer-term psychiatric assistance than in previous similar episodes.

Clinical treatment of posttraumatic stress disorder: conceptual challenges raised by recent research

OBJECTIVE

This paper highlights some of the recent findings in the field of posttraumatic stress disorder (PTSD) and examines their impact on conceptions of trauma-focused clinical treatment.

METHOD

A series of research findings in the area of epidemiology, phenomenology, neurobiology and treatment are summarised.

RESULTS

The findings from these studies present critical challenges for clinicians who wish to treat trauma survivors using specialised trauma treatments. The major challenge is one of avoiding a simplistic view of PTSD as a singular response to trauma, as this perception may result in an underestimation of the complexity and disabling quality of the disorder, and lead to the formulation of treatment plans that are simplistic or incomplete.

CONCLUSIONS

A more precise characterisation of the nature and range of the stress responses of trauma victims will significantly improve treatments of trauma survivors.

Psychological debriefing: controversy and challenge

OBJECTIVE

The efficacy of psychological debriefing following potentially traumatising events has become extremely controversial. This review aims to identify the issues underlying this controversy and their theoretical, social and political ramifications which are important in other areas of psychiatry and the social sciences.

METHOD

The historical background to the debriefing debate and the (largely negative) results of recent randomised controlled trials (RCTs) are reviewed.

RESULTS

Despite the negative results of recent RCTs, psychological debriefing remains the most widely used structured intervention following potentially traumatising events, designed to reduce the incidence of long-term psychiatric morbidity. The clinical relevance these trials and their applicability in vivo is questioned. There are implicit difficulties in conducting rigorous randomised controlled trials of group debriefing, and such trials may be unachievable.

CONCLUSIONS

Demonstrating the efficacy of debriefing or other preventive interventions presents major challenges to investigators and it is unlikely the controversy will be resolved in the near future.

Follow-up study of concentration camp survivors from Bosnia-Herzegovina: three years later

Concentration camp survivors from Bosnia-Herzegovina, now refugees in the Netherlands, were given early outpatient treatment for posttraumatic stress disorder (PTSD) for 6 months. They were tested with the Watson Questionnaire before entering therapy, after 6 months and 3 years later when a structured interview designed to obtain information on psychosocial status was administered. Data were analyzed with PCA-STAT 1.1 statistical package. The treatment was effective on a short-term basis with some long-term effects. Elderly people were no more vulnerable to the onset of PTSD than younger ones but were more resistant to therapy. Psychosocial factors had neither protective nor risk value for the development of PTSD in this group.

Predicting PTSD in trauma survivors: prospective evaluation of self-report and clinician-administered instruments

BACKGROUND

This study examined the ability of commonly used questionnaires and a structured clinical interview to predict PTSD in recent trauma survivors.

METHOD

Horowitz's Impact of Event Scale (IES), Speilberger's State Anxiety (SANX) and the Peri Traumatic Dissociation Questionnaire (PDEQ) were administered one week post-trauma to 239 traumatised individuals recruited from a general hospital emergency room. The IES, the SANX, the civilian version of the Mississippi Scale for Combat Related PTSD (MISS), and the Clinician Administered PTSD Scale (CAPS) were administered one month and four months post-trauma. Receiver operator characteristic (ROC) analysis was used with these data.

RESULTS

All questionnaires were better than chance at predicting PTSD. The so-called PTSD questionnaires (IES and MISS) were not better than the more general ones. No difference in predictive value was found when questionnaires were carried out one week or one month after a trauma. Recovery was better predicted than PTSD, and the CAPS was better than the questionnaires.

DISCUSSION

The use of psychometrics and clinical interviews to predict PTSD should be guided by clinical relevance and by the availability of resources.

Care of a patient with post-traumatic stress disorder

Amanda, a single 22-year-old woman, was involved in a road traffic accident One passenger died and another received a number of serious injuries. Amanda received injuries that required hospitalization and reconstructive surgery; from which she made a full recovery. Following discharge from hospital, Amanda developed a number of symptoms consistent with post-traumatic stress disorder. One month after the accident Amanda was referred to the community psychiatric nursing service by her district nurse. After treatment which comprised debriefing, relaxation and desensitization Amanda reported a significant improvement in her symptoms and was able to return to work. Amanda had no previous history of mental health problems.

Post-traumatic stress disorder in brain injury patients

In the absence of the recognition of the emotional sequelae following traumatic brain injury (TBI), many patients are deprived of adequate treatment. The purpose of the current study is to evaluate the prevalence of post-traumatic stress disorder (PTSD) and explore the clinical picture among TBI patients. Twenty four outpatients with diagnosed head injuries following various traumas filled out standardized questionnaires, assessing post-traumatic residuals. Thirty-three per cent of these patients met criteria for PTSD diagnosis. The clinical picture of PTSD following TBI is somewhat distinguished from those following other traumatic events. Issues concerning the specific nature of the syndrome following TBI, and the difficulties in differentiating between PTSD and postconcussive syndrome, are discussed.

Seven-year follow-up of child survivors of a bus-train collision

OBJECTIVE

To assess the long-term effects of a traumatic bus-train collision and to examine the effect of levels of exposure and immediate reactions on long-term adjustment.

METHOD

Seven years after the accident, 389 subjects, all doing compulsory army service, filled out self-report questionnaires assessing symptoms of posttraumatic stress disorder (PTSD), psychiatric symptomatology, and military functioning. In addition, subjects were questioned about their immediate reactions to the traumatic event.

RESULTS

The most highly exposed subjects reported the highest levels of somatization, depression, phobic anxiety, and psychoticism and more PTSD symptoms. Acute stress symptoms and manifestations of fear immediately after the accident were strongly related to long-term maladjustment

CONCLUSIONS

The results suggest that the investigation and assessment of long-term adjustment after traumatic events should take into account both contextual factors, such as the level of exposure to the event, and personal factors, such as the victims' immediate reactions.

Psychological sequelae following the Gulf War. Factors associated with subsequent morbidity and the effectiveness of psychological debriefing

BACKGROUND

The aim was to study the effect of brief counselling and psychological debriefing following a trauma on subsequent morbidity.

METHOD

We investigated psychological morbidity in 62 British soldiers whose duties included the handling and identification of dead bodies of allied and enemy soldiers during the Gulf War. Of these soldiers, 69% received a psychological debriefing on completion of their duties. The subjects completed by post a demographic questionnaire, the General Health Questionnaire (GHQ-28) and the Impact of Events Scale.

RESULTS

After nine months 50% had evidence of some psychological disturbance suggestive of posttraumatic stress disorder (PTSD); 18% had sought professional help; 26% reported relationship difficulties. Neither prior training nor the psychological intervention appeared to make any difference to subsequent psychiatric morbidity. Morbidity at nine months was more likely in those with a history of psychological problems and those who believed their lives had been in danger in the Gulf.

CONCLUSIONS

These findings show that a psychological debriefing following a series of traumatic events or experiences does not appear to reduce subsequent psychiatric morbidity and highlights the need for further research in military and civilian settings.

The continuity principle: a unified approach to disaster and trauma

The continuity principle stipulates that through all stages of disaster, management and treatment should aim at preserving and restoring functional, historical, and interpersonal continuities, at the individual, family, organization, and community levels. Two misconceptions work against this principle and lead to decisional errors: the "abnormalcy bias" which results in underestimating victims' ability to cope with disaster, and the "normalcy bias" which results in underestimating the probability or extent of expected disruption. This article clarifies these biases and details the potential contributions of the continuity principle at the different stages of the disaster.

Brief therapy in a battleshock recovery unit: three case studies

Combat stress reactions may present in many forms. This study presents three cases from the Gulf War which illustrate the diversity of presentation and demonstrate the ways in which the principles of the management of Combat Stress Reactions--Proximity, Immediacy and Expectancy--can be combined with specific individual therapies.

Post-traumatic stress disorder

The management of post-traumatic stress disorder depends on the nature of the stress, the personality of the victim, and the clinical orientation of the therapist. Traumatic situations may be experienced by individuals or by groups, and may be isolated incidents (such as unexpected civil disasters) or continuing occupational hazards, such as are experienced by soldiers, firemen or police. The first concern of therapists, whatever their methods of treatment, is an understanding of the nature of the trauma, and of the inherent differences in each type. This paper seeks to identify such differences. Some general therapeutic principles are then suggested.

Symptoms of post-traumatic stress disorder in Falklands veterans five years after the conflict

A group of 64 Falklands war veterans who were still serving in the British Army were studied and compared with a group of matched controls. Half the veterans reported some symptoms of post-traumatic stress disorder, and 22% were rated as having the complete PTSD syndrome. Presence of the symptoms was associated with intensity of combat experience and the retrospective report of emotional difficulties in the initial period on return from the war.