Jacob D. Lindy

Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample

Research has indicated significant comorbid psychopathology with chronic posttraumatic stress disorder (PTSD) in samples of war veterans. The present paper examines the issue of comorbidity in a disaster sample to learn whether findings from veterans generalized to this event. A total of 193 subjects exposed to the Buffalo Creek dam collapse of 1972 were examined 14 years later using diagnoses derived from the Structured Clinical Interview for DSM-III (SCID). Past and present PTSD was found in a significant portion of the sample. Major depression was the next most common diagnosis and was highly related to PTSD. Anxiety disorders were also common. The overlap with other diagnoses was quite similar to that found in a sample of Vietnam veterans we studied earlier, except that the disaster sample had fewer dysthymic disorders, substance abusers, and antisocial personality disorders. Possible explanations for comorbidity in chronic PTSD were discussed and it was suggested that the morphology of PTSD may be quite stable in at least some other nonveteran trauma populations.

Posttraumatic stress disorder. Toward DSM-IV.

This report raises conceptual issues about the validity of the posttraumatic stress disorder diagnosis as described in DSM-III. The helpfulness of DSM-III is acknowledged, but gaps in that classification are noted. These are organized into three areas: the etiology of the disorder, its natural history, and diagnostic specificity. Suggestions are made for conceptualizing these issues and for research that needs to be undertaken to help resolve them. The authors urge more theoretical and empirical attention to these important issues in the upcoming years, so that later diagnostic descriptions and understandings will be more precise.

Multiple diagnosis in posttraumatic stress disorder. The role of war stressors.

Prior studies have shown that posttraumatic stress disorder (PTSD) in Vietnam veterans is associated with various aspects of war stressors and that other diagnoses often co-occur with PTSD in this population. The present report examines the prediction of other diagnoses, in combination with PTSD, from a variety of war stressor experiences in a broad sample of veterans recruited from clinical and nonclinical sources. The results show that PTSD with panic disorder is better explained by war stressors than other diagnostic combinations and that high-risk assignments and exposure to grotesque deaths were more salient than other stressor experiences in accounting for different diagnostic combinations. Implications of the findings for PTSDs placement in the DSM-III-R and for psychological and pharmacological treatments were discussed.

Race differences in response to combat stress

A number of authors have written poignantly about the Black experience in the Vietnam war; however, very little research has addressed this topic. The present report studied race differences in preservice, stressor, and outcome variables in a community sample of 181 war veterans. Blacks reported higher levels of stressors and outcome, particularly for PTSD-related symptoms. The results suggested that the relationship between stressors and outcome can be defined by a common regression line for Blacks and Whites, and that the high symptom levels observed for Blacks in the sample were accounted for by higher levels of stressors during their war experience. The cognitive coping mode of avoidance did not conform to this pattern and showed higher levels for Blacks even controlling for other factors. Potential cultural origins of this difference were noted.

War stressors and symptom persistence in posttraumatic stress disorder

Abstract This study focused on delineating aspects of war stressors associated with risk for posttraumatic stress disorder in Vietnam veterans. Findings from 191 Vietnam war veterans are presented, addressing which elements of the war experience predicted PTSD in remission or persistent PTSD. Some experiences, like loss and injury, predicted having had PTSD symptoms in the past, while other experiences, such as exposure to grotesque death, predicted current (persistent) PTSD. Discriminant analysis showed that the more extreme/intense the stressor experiences, the higher the risk for developing PTSD and for persistent symptoms. These findings provide empirical support for the PTSD diagnosis and additional data for refining the PTSD stressor criterion.

The Buffalo Creek Disaster

The collapse of the Buffalo Creek dam and subsequent flood disaster has received a great deal of attention in the literature since its occurrence in 1972. Previous reports of that disaster covered its legal (Stern, 1976), sociological (Erikson, 1976), and psychological (Gleser, Green, & Winget, 1981; Titchener & Kapp, 1976) aspects.

Focal Psychoanalytic Psychotherapy of Posttraumatic Stress Disorder

Psychoanalytic psychotherapy of posttraumatic stress disorder (PTSD) distinguishes itself from other treatment modalities in that its focus is on the meaning of trauma-related symptoms and behaviors and on the meaning of catastrophic life events to the person as a whole. The analytically oriented therapist is also curious about the ways in which a person’s psyche and soma fend off, experience, cope, and adapt to extreme stress. The analyst is concerned about the dilemmas which the person in the traumatic situation faced, and faces, as a result, in the present. The therapist uses introspection, intuition, and empathy in order to try to comprehend and then verbalize a dilemma which stretches beyond his or her own internal experience. The analytic therapist hopes that insights regarding the meaning of symptoms, both conscious and unconscious, and the consequences of catastrophe can be utilized by the survivor to identify and help master future danger situations and to try to make whole again the fabric of life.

Somatic Reenactment in the Treatment of Posttraumatic Stress Disorder

Somatic reenactments, like other intrusive symptoms in post-traumatic stress disorder, such as flashbacks and nightmares, reproduce the mental content of traumatic events. Four cases are presented from survivors of military trauma and civilian catastrophes. The patients were part of larger research projects carried out by the University of Cincinnati Traumatic Stress Study Center. Understanding such symptoms as repetitions of the trauma itself proved useful therapeutically, especially in consolidating the working alliance.

Exploring the Trauma Membrane Concept

As part of the healing process in the aftermath of catastrophic stress, the trauma membrane forms as a temporary psychosocial structure to promote adapta- tion and healing. The trauma membrane acts as an intrapsychic and interpersonal mediator, interfacing between the person and the traumatic memories and every- day reminders of the traumatic event from the external world. Therapists work at the boundary of this psychological buffer zone. The multidimensional concept of a trauma membrane reflects intrapsychic, interpersonal, and communal processes that protect individuals and communities, such that a survivor network or individual survivor will invite or block access to mental-health intervention. The intrapsychic mechanism protects traumatized individuals from being subsequently overwhelmed by intrusive memories by cordoning off those memories until they can be handled by the individuals adaptive psychic processes. This chapter will explore the definition and history of the trauma membrane concept, the similarities and differences between the stimulus barrier and trauma membrane, its value as a metaphor, and how the recovery environment can facilitate its formation in the aftermath of a trauma. As a flexible analogy, the multi- level trauma membrane can help researchers and clinicians explain trauma-related processes and their clinical applications.

On the process of becoming a psychotherapist: An outline of a core-curriculum for the teaching and learning of psychoanalytic psychotherapy

T 0 CONTEMPLATE the process of becoming a psychotherapist-in isolation from current trends in psychiatric training, in general, and from the political and economic pressures upon our field, in particular-would be short-sighted and unrealistic. Faculty and residents are involved in a rapidly changing service delivery system; they have to cope with an expanding fund of pertinent biological and psychological knowledge, and a “pluralism” of therapeutic modalities. Funds for residency training programs are now more frequently supplied by local sources which steadily increase the demand both for accountability and for service. Such demands, along with the economic pressures, have led to questioning the cost-benefit ratio of psychoanalytic psychotherapy. Therefore, a major challenge, if not the major challenge for psychiatric education today, is to reexamine the value of the teaching of psychoanalytic psychotherapy as the central aspect of residency curriculum. This challenge should be welcomed. It should stimulate us to rethink the problems related to the teaching and practice of psychoanalytic psychotherapy, which should benefit from a new look at our pedagogic methods. We can then bring the results of our reevaluation into our clinics and into academia-the open market place of conflicting ideas and approaches-where they can be tested and compared for the benefit of our patients and trainees and for the benefit of our science as well. It is entirely in the spirit of this open exchange with other approaches that we will now limit our discussion to the process of becoming a psychoanalytic psychotherapist. We have selected some problems of pedagogy related to the teaching of psychoanalytic psychotherapy as the central theme for this discussion, carrying one step further a previous consideration of similar issues which will make some repetition of earlier expressed ideas unavoidable.’ Three questions will bring these pedagogic problems into focus. (1) How to teach psychotherapy in a manner that will permit the immediate translation of what is learned into actual patient care. (2) What methods are there at our disposal to help the future psychiatrist (short