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DIRECTIONS

Volume 10 Lesson 1

Acute Stress Reactions


Among Victims of Violence:
Assessment and Treatment
Cheryl Gore-Felton, PhD

Dr. Gore-Felton is Assistant Professor, Department of Psychiatry and Behavioral Medicine,


Medical College of Wisconsin.

Introduction
A substantial body of research on violence, particularly on combat-related violence, indicates that exposure to vio-
lence may cause acute and chronic psychological responses which include, but are not limited to: fear, anger, recur-
rent distressing thoughts, anxiety, depression, and startle responses (Bisson & Shepherd, 1995; Helzer, Robbins, &
McEvoy, 1987; Kilpatrick, Saunders, Amick-McMullan, Best, Veronen, & Resnick, 1989; Marmar, 1991; Solomon,
Mikulincer, & Benbenistry, 1989). However, there is a relatively limited body of research that focuses specifically on
the immediate psychological impact of violence that occurs to civilians.
This lesson focuses on the psychological trauma that can occur in the immediate aftermath of interpersonal vio-
lence. The research cited in this lesson includes studies of victims and observers of various forms of interpersonal
violence: rape, threats by a patient, legal execution, terrorist attack, ambush, assassination, mass shootings, and other
forms of homicide. The empirical evidence indicates that individuals commonly experience disruptive psychological
symptoms immediately following violence. Furthermore, there is evidence suggesting that acute stress reactions can
lead to posttraumatic stress disorder (PTSD). The limited amount of research conducted on treatment interventions
on acute stress reactions to violence indicates that there is no one best intervention. However, the high prevalence of
acute stress reactions among victims immediately following interpersonal violence, coupled with evidence that acute
stress symptoms predict PTSD, underscore the importance of providing early inter vention aimed at reducing acute
trauma symptoms in victims of interpersonal violence.

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Volume 10 Lesson 1

After completing this lesson, clinicians will be able to statistics are severe. Homicide is the second leading
(1) recognize the symptoms of acute stress disorder cause of death for persons 15–24 years old; however,
(ASD), (2) assess patients for ASD symptoms, and (3) it is the leading cause of death for 15–24-year-old
identify therapeutic interventions aimed at reducing African American and Hispanic youth.
ASD symptoms. Women are particularly likely to be targets of vio-
Clinicians who are able to recognize and assess ASD lent behavior. The National Victim Center and Crime
symptoms will increase the likelihood that patients will Victims Research and Treatment Center (1992)
receive appropriate treatment aimed at reducing trauma reported that approximately 12 million (12.9%)
symptoms. Moreover, the earlier patients receive treat- women had been raped at least once during their life-
ment for acute stress responses, the less likely the time. Moreover, when women are victimized by male
patient is to suffer from chronic posttraumatic stress partners they are more likely to be repeatedly attacked,
symptoms. raped, injured, or eventually killed than are women
who are assaulted by other perpetrators (Browne &
Prevalence of Interpersonal Williams, 1989, 1993; Finkelhor & Yllo, 1985).
Violence Resnick and colleagues (1993) used multistage geo-
graphic sampling among 4009 adult (18 years or older)
Background: women living in the United States and found that more
Interpersonal violence is defined here as an event than one-third (35.6%) indicated experiencing at least
that threatens or manifests bodily or emotional one of the following: rape, sexual molestation,
harm. The violent event may be observed, threat- attempted sexual assault, physical assault, and homicide
ened, or directly experienced. Interpersonal violence of close friend or relative. Additionally, 32.5% reported
can take a wide variety of forms. These include experiencing more than two different types of crime.
domestic violence; physical, sexual, and emotional Additionally, 32.5% of the 4009 adult women reported
abuse of children and spouses; date rape and experiencing more than two different types of crime.
stranger rape; assault and battery of strangers; ter- The high prevalence of interpersonal violence, par-
rorist attacks; mass shootings; assassinations; and ticularly among women, underscores the need for clini-
executions. The studies discussed here relate to the cians to understand the psychological consequences of
majority of these forms of violence, and examine acute an understudied realm (i.e., the immediate and short-
stress reactions not only among victims but also among term effects of violence).
observers of violence. Suicides, or other forms of vio-
lence that are outside of the realm of interpersonal vio- Psychological Sequelae of
lence, are not included in this lesson. Violence
Unfortunately, interpersonal violence has become a The intensity of an individual’s initial response to a
common traumatic experience in the lives of many traumatic event has been found to be associated
individuals in the United States. The most recent report with an elevated risk of developing PTSD (Koop-
by The Centers for Disease Control and Prevention, man, Classen, and Spiegel, 1994; Feinstein and Dolan,
National Center for Injury Prevention and Control 1991). PTSD is a chronic disorder in which a person
(1996) reported that in 1994, homicide claimed the who has experienced a traumatic event and
lives of 24,926 Americans. Also, according to this responded with intense fear, helplessness, or horror
report, there were over 38,505 firearm-related deaths, persistently reexperiences the traumatic event,
including 17,866 firearm-related homicides, 18,765 avoids stimuli associated with the trauma, and per-
firearm-related suicides, and 1,356 unintentional sistently experiences increased arousal for longer
deaths related to firearms. Law enforcement agencies than one month according to the Diagnostic and Sta-
in the United States reported 71 forcible rapes per tistical Manual of Mental Disorders, fourth edition
100,000 females in 1996 (Federal Bureau of Investiga- (DSM-IV) (American Psychiatric Association, 1994).
tion, 1997). For minority populations, the violence McFarlane (1986) observed that the detection of much

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Acute Stress Reactions Among Victims of Violence: Assessment and Treatment Gore-Felton

posttrauma morbidity is delayed, in part due to prob- ment, or absence of emotional responsiveness; reduc-
lems in diagnosis. The prevalence of PTSD in the gen- tion in awareness of surroundings (e.g., being “in a
eral adult population is estimated to be 1% (Helzer et daze”); derealization; depersonalization; and dissocia-
al. 1987), but in some subpopulations the rates are esti- tive amnesia. The diagnosis then requires one each of
mated to be much higher. For example, the highest the three classical PTSD symptom clusters: (1)
rates of lifetime PTSD (38.5%) and current PTSD intrusion or flashbacks (e.g., reexperiencing the trau-
(17.8%) were found among women who experienced matic event), intrusive thoughts, or nightmares; (2)
physical assault and women with a history of rape avoiding reminders of the traumatic event; and (3)
(Resnick et al. 1993). It has been estimated that 15.2% anxiety/hyperarousal, including difficulty concen-
of male Vietnam veterans suffer from PTSD (Marmar, trating, restlessness, and exaggerated startle
1991). Thus, identifying characteristics in individuals response. Finally, the diagnosis requires impairment in
who are at greatest risk for developing PTSD will important areas of social and/or vocational functioning
enable patients to receive early treatment and reduce (Spiegel et al. 1996). The five categories of symptoms
the incidence of chronic trauma symptoms. are described below.
A growing body of evidence suggests that there are
specific acute stress symptoms which occur almost Dissociation:
immediately following a traumatic event and predict Dissociation is a disjunction in memory, perception,
the development of PTSD (Koopman et al. 1994; or identity either during or after experiencing a dis-
Classen, Koopman, Hales and Spiegel, in press; Shalev, tressing event. Research indicates that dissociative
Peri, Canetti, & Schreiber, 1996). The observation of experiences follow different types of traumatic experi-
acute stress reactions, in these and other studies of nat- ences, including childhood sexual abuse (Briere, Evans,
ural and human-caused disasters, led to the formation Runtz, & Wall, 1988; Heath, Bean, & Feinauer, 1996),
of the acute stress disorder (ASD) diagnosis in the combat (Marmar, Weiss, Schlenger, Fairbank, Jordan,
DSM-IV (Spiegel, Koopman, Cardena, & Classen, Kulka, & Hough, 1994), and natural disasters (Koop-
1996). man, Classen, & Spiegel, 1994).
Dissociation appears to be an acute reaction to
Acute Psychiatric Symptoms interpersonal violence. For example, Dancu and col-
Associated with Violence leagues (1996) found that immediately following sexual
Research indicates that in the immediate aftermath of a and nonsexual assaults, victims experienced more disso-
traumatic event such as interpersonal violence, people ciative symptoms in comparison with individuals who
may experience distress and impaired psychological had not been victimized. Additionally, among women
functioning to a degree that necessitates clinical inter- who had been raped or who were victims of an
vention (Koopman, Classen, Cardena, & Spiegel, attempted rape, approximately 85% of the women
1995). These psychological symptoms may be clinical reported experiencing the feeling of being detached
indicators of ASD. The DSM-IV diagnosis of ASD (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992).
describes psychological symptoms that persist for a These results are consistent with other acute trauma
minimum of two days but not longer than four research. For example, among survivors of a mass
weeks following the traumatic event. The occur- shooting in a cafeteria in Killeen, TX, in 1991, 11%
rence of symptoms beyond four weeks of a trauma reported having amnesia and 8% reported experiencing
must be evaluated in accordance with the PTSD emotionally numb feelings (North, Smith, & Spitz-
diagnosis (APA, 1994). nagel, 1994). Among media eyewitnesses to an execu-
ASD has five categories of symptoms that occur for tion, 53% reported experiences of psychic numbing,
two or more days within the first four weeks following such as feeling distant from their emotions and no
a traumatic event (see Table 1). One symptom cate- longer feeling interested in previously enjoyable activi-
gory includes dissociative symptoms, which are ties (Freinkel, Koopman, & Spiegel, 1994). Moreover,
three (or more) of the following: numbing, detach- 53% of the eyewitnesses also reported that things

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Volume 10 Lesson 1

Tab le 1
ACUTE STRESS DISORDER

Duration of Symptoms Symptom Category Symptoms

48 hours to 4 weeks Dissociative (three or more) (1) numbing, detachment,


absence of following trauma
emotional responsiveness
(2) “being in a daze”
(3) derealization
(4) depersonalization
(5) unable to recall important
aspects of the trauma
(dissociative amnesia)

48 hours to 4 weeks Intrusion (requires one) (1) recurrent images, thoughts,


dreams, illusions, flashback
episodes
(2) sense of reliving the trauma
(3) distress on exposure to
reminders of the trauma

48 hours to 4 weeks Avoidance (requires one) (1) avoids reminders of the


trauma (i.e., thoughts, feelings,
conversations, activities, places,
people)

48 hours to 4 weeks Arousal (requires one) (1) difficulty sleeping


(2) irritability
(3) poor concentration
(4) hypervigilance
(5) exaggerated startle response
(6) motor restlessness

48 hours to 4 weeks Impairment (requires one) (1) significant distress in social


functioning
(2) significant distress in
occupational functioning
(3) significant distress in some
other important area of one’s
life

around them seemed unreal and that they experienced old son in an apartment. She sought psychologi-
a sense of timelessness (i.e., symptoms of derealization). cal services because she was experiencing a “weird
Forty percent of the witnesses experienced themselves sensation” whenever her husband kissed her.
as strangers and felt distant from their own thoughts Specifically, whenever her husband began kissing
(i.e., symptoms of depersonalization). her, she felt like her body was floating above her.
This sensation distresses her to the point that she
Case Example of Dissociation pulls away from her husband in an attempt to
stop the disturbing sensation of floating. She has
Maria is a 28-year-old Hispanic woman. She is
never experienced this sensation before, and
married and lives with her husband and 3-year-
noticed it began about two weeks ago.
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Acute Stress Reactions Among Victims of Violence: Assessment and Treatment Gore-Felton

During the assessment, the therapist learned that respondent experienced at least one symptom of reex-
three weeks prior to seeking psychotherapy Maria periencing the traumatic event.
had been robbed at knife point by an assailant Nearly all of the participants in a study of victims of
who came up behind her in a parking lot as she rape or attempted rape (Rothbaum et al. 1992) experi-
was getting into her car. The assailant held the enced trauma-related intrusive thoughts and images at
knife to her throat and demanded her purse. After the initial assessments (which were conducted an aver-
Maria gave the assailant her purse, he licked her age of 12.64 days postassault); 74% reported a sense of
cheek leaving saliva on her face. reliving the experience; and 86% reported experiencing
flashbacks. In a study of nonsexual and sexual forms of
assault against women, perceptions about general con-
Reexperiencing the Traumatic Event: trollability of negative events were related to greater
Reexperiencing the trauma in the DSM-IV criteria for symptoms of reexperiencing the trauma (Kushner,
ASD is indicated by persistent unbidden intrusions Riggs, Foa, & Miller, 1993).
such as by recurrent images, thoughts, dreams, illu-
sions, or flashbacks (APA, 1994). Additionally, upon Case Example of Reexperiencing the Trauma
exposure to the reminders of the traumatic event,
there is often a strong sense of reliving the experi- Along with the sensation of floating, Maria has
ence or extreme distress. also been experiencing nightmares. She dreams
Reexperiencing the traumatic event is not uncom- an assailant is threatening her with a knife.
mon among victims of violence. For example, in the
During the day, she has moments where she will
study of psychological reactions of media eyewitnesses
“see” the knife vividly in her mind.
to an execution, flashbacks were experienced by 13% of
the journalists who attended the execution. Forty per-
cent of the participants experienced repeated and Avoiding Reminders of the
unwanted memories of the execution, and 27% Traumatic Event:
reported repeated distressing dreams about the execu- Several research studies indicate that avoiding
tion (Freinkel et al. 1994). Among children who had reminders of the traumatic event occurs in many indi-
been present on a school playground at the time of a viduals across various types of violent situations. For
sniper attack, 97.1% reported intrusive thoughts, and example, avoiding reminders of the traumatic event was
88.6% reported intrusive imagery and sounds (Pynoos, reported among 88% of children approximately one
Frederick, Nader, Arroyo, Steinberg, Eth, Nunez, & month after they experienced the sniper attack at their
Fairbanks, 1987). school playground (Pynoos et al. 1987). In addition,
Providing even more evidence that reexperiencing survivors of a mass shooting in Texas reported avoiding
the traumatic event occurs almost immediately follow- reminders (47%) and thinking (37%) about the event,
ing a trauma in some individuals, are the intrusive when they were assessed approximately one month
thoughts that were experienced by the survivors of a postdisaster (North et al. 1994). Also, in the study
terrorist attack in Israel (Shalev, 1992). Also, 86% of examining acute stress reactions to a mass shooting in
the soldiers caught in an ambush in Namibia reported an office building in San Francisco, respondents experi-
recurrent and intrusive recollections of the event, and enced a mean of 1.0 possible symptoms of avoiding
half experienced recurrent dreams of the event (Fein- reminders of the traumatic event (Shalev, Peri, et al.
stein, 1989). Furthermore, 82% of the people involved 1996). In the study of rape and attempted rape vic-
in the mass shooting in Killeen, TX, experienced intru- tims, 93% of the victims who were assessed an average
sive thoughts and 37% reported flashbacks (North et of 12.6 days post-assault reported avoidance symptoms
al. 1994). Classen and colleagues (in press) found that (Rothbaum et al. 1992).
when examining acute stress reactions to a mass shoot-
ing in an office building in San Francisco, the average

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Volume 10 Lesson 1

Case Vignette of Avoidance Impairment in Social, Occupational, and


Other Important Areas:
Despite Maria’s efforts not to think about the Severe impairment in social, occupational, or other
attack, she continues to be troubled by what hap- important areas of functioning has been included as a
pened to her. She thought that changing where diagnostic criteria for ASD among survivors of a recent
she shops for groceries and staying away from the traumatic event (APA, 1994). The available literature
street would help her to “get over it.” on acute stress reactions indicates that this often occurs
among victims of interpersonal violence. Eighty-one
percent of women who were assessed soon after a rape
Anxiety/Hyperarousal: or an attempted rape (on average, 12.6 days postas-
Symptoms of hyperarousal/anxiety in the DSM-IV sault) reported an impairment in leisure activities
criteria for ASD are indicated by marked difficulty (Rothbaum et al. 1992). Difficulty in concentrating
sleeping, irritability, poor concentration, hypervigi- and a loss of interest in significant activities was
lance, exaggerated startle response, and motor rest- observed among 65.7% of children survivors of the
lessness (APA, 1994). sniper attack in their school playground approximately
The available empirical literature indicates that this one month after the incident took place (Pynoos et al.
response is not uncommon among victims who experi- 1987).
ence violence. For example, difficulty in concentrating
and a loss of interest in significant activities was Case Vignette of Impairment
observed among 65.7% of children survivors of the
sniper attack in their school playground approximately Since the attack, Maria quit her duties as a “car-
one month after the incident took place (Pynoos et al. pool mom” because she found that she could not
1987). In addition, 97% of women who were raped or
concentrate on driving. She ran a stop sign that
victims of attempted rape exhibited a startle response
she didn’t see because, “My head was in the
(Rothbaum et al. 1992). Among survivors of a mass
clouds.” Until she can “get it together,” she no
shooting (North et al. 1994), 44% were found to expe-
longer feels safe driving her son or other children
rience irritability, 75% were jumpy and startled easily,
to pre-school.
and 74% suffered from insomnia. In research on sexual
and nonsexual criminal assaults on women, it was not
reported how many of the individuals experienced Treatment
PTSD symptoms; however, it was reported that arousal The empirical literature demonstrates the effective-
was inversely associated with perceived controllability ness of the following four types of clinical strategies
of negative events (i.e., the less perceived control in treating acute stress reactions: cognitive-behav-
women thought they had, the more severe were their ioral; immediate versus delayed treatment; brief psy-
hyperarousal symptoms) (Kushner et al. 1993). chotherapy; and critical incident stress debriefing.
The use of psychopharmacology in the treatment of
Case Vignette of Hyperarousal acute stress disorder will also be discussed.

Maria has difficulty falling and staying asleep. Cognitive-Behavioral Treatment:


She is also aware that whenever her back is to the Cognitive-behavioral therapy merges two theories.
door and someone comes into the room, she Cognitive theory supposes that behavior is sec-
“jumps.” Then, her heart pounds and it takes her ondary to a person’s thoughts while behavioral the-
several minutes to quiet herself. ory infers that behavior is not a result of how we
think, but is contingent upon rewards and punish-
ments. Cognitive approaches rely heavily on the asser-

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Acute Stress Reactions Among Victims of Violence: Assessment and Treatment Gore-Felton

tion that an individual’s affect and behavior are largely the following: initial PTSD severity, type of assault,
determined by the way he/she structures the world. severity of the assault, demographics, and time since
Therefore, effective therapeutic techniques should assault. The brief prevention program consisted of four
be designed to (1) identify how the person interprets 2-hour weekly sessions of cognitive-behavioral therapy.
his or her environment, (2) reality test the person’s The sessions incorporated education about reactions to
perceptions, and (3) correct distorted perceptions or assault, breathing and relaxation training, reliving the
beliefs. The therapeutic goal is to get the person to assault, in vivo exposure, and cognitive restructuring.
perceive their environment and the interactions he The women in the assessment control group were given
or she has in it more realistically and adaptively. The five assessment interviews each lasting 90 minutes dur-
behavioral changes impact cognitions or beliefs. ing a 12-week period. At a follow-up assessment five
Patients are often given weekly activity logs, pleasure and a half months later, none of the participants in
schedules, etc. to monitor their reactions to situations the therapy group compared to 33% of the partici-
and subsequent behaviors. These weekly logs or home- pants in the assessment group had more than six
work assignments are particularly good at assisting the PTSD symptoms. It is also noteworthy that the ther-
therapist ascertain underlying, often unconscious apy group was effective in reducing depression. For
assumptions that fuel psychological symptoms. For example, there were no reports of depression among the
example, a woman who was raped may hold the erro- group therapy participants, while 56% of the assess-
neous belief that if she can just put the ordeal behind ment group reported moderate to severe depression.
her she can get on with her life. The behavior that fol- A study which compared the effectiveness of cogni-
lows is an avoidance of all places, people, and things tive restructuring with progressive muscle relaxation in
that remind her of the attack and eventually results in treating rape victims who were suffering from acute
an inability to leave her house. Now that the therapist is PTSD symptoms demonstrated that time can be an
aware of the underlying assumption fueling the behav- important factor in the resolution of trauma symptoms
ior, the therapist can begin to develop interventions (Echeburua, de Corral, Sarasua, & Zubizarreta, 1996).
aimed at debunking the maladaptive beliefs and assist- The average time since the rape for the participants was
ing the patient in developing cognitions that restore approximately five weeks. Twenty women were ran-
premorbid functioning. Many effective behavioral domly assigned to one of the two treatment conditions
components aimed at reducing trauma symptoms (cognitive restructuring or muscle relaxation). When
incorporate breathing and relaxation exercises because looking at global intensity of PTSD symptoms, the
many trauma survivors suffer from symptoms of anxi- researchers found that women who were in the cog-
ety and hyperarousal, which respond well to these exer- nitive restructuring and coping skills group showed
cises. slight improvement at the follow-ups at one and six
A study examining the efficacy of a brief cognitive- months compared to the muscle relaxation group.
behavioral treatment program on recent assault victims At the 12-month follow-up the cognitive restructuring
demonstrated an increased rate of improvement on group showed significant improvement in PTSD symp-
trauma-related psychological symptoms (Foa, Hearst- toms compared to the muscle relaxation group. When
Ikeda, & Perry, 1995). The study examined 20 women the researchers examined which PTSD symptoms were
who had been recently sexually or nonsexually effected by the cognitive-restructuring and coping skills
assaulted. The women were placed into one of two dif- group, they found that there was marked improvement
ferent groups: ten in a brief prevention group of cogni- in reexperiencing and avoidance symptoms. This is an
tive-behavioral therapy and ten in an assessment con- extremely important clinical finding in light of the fact
trol group. Eighteen out of the 20 women were less that the most frequently experienced symptoms in
than 14 days post-assault, and were thus in the early PTSD are reexperiencing and autonomic arousal symp-
acute stress phase of responding to the traumatic event. toms (Resnick et al. 1993; Rothbaum et al. 1992; Foa,
The women in the assessment control group were Zimbarg, & Rothbaum, 1992).
selected to match those in the brief prevention group in Veronen and Kilpatrick (1983) report that stress

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Volume 10 Lesson 1

inoculation training has been effective in reducing or systematic desensitization therapy (SDT). A total of
fear, anxiety, and depression related to rape trauma. 71 participants were assigned to CBT and 67 were
To further this research, a study was conducted examin- assigned to SDT. The participants were matched on all
ing the effectiveness of stress inoculation training, pro- demographic features and severity of assault (i.e., loca-
longed exposure, supportive counseling, and wait-list tion of rape, use of a weapon, number of assailants, and
control (Foa, Rothbaum, Biggs, & Murdock, 1991). degree of physical violence).
Forty-five women who had been raped at least three The researchers found no significant differences
months prior to entering the study were randomly between the two different treatment modalities on psy-
assigned to one of the four treatment conditions. The chological or social adjustment measures. Furthermore,
researchers found that stress inoculation training and there was no difference between early-treatment seekers
prolonged exposure were more suitable treatment and late-treatment seekers at the end of treatment on
methods than supportive counseling or wait-list control self-report measures of psychological symptomatology.
in reducing PTSD symptoms.
Brief Psychotherapy:
Immediate Versus Delayed Treatment: Brom, Kleber, and Defares (1989) conducted a com-
Behavior therapy is based on the basic assumption parative outcome study in which they examined three
that maladaptive or disruptive behavior is not con- types of psychotherapy: trauma desensitization, hypno-
tingent upon insight. Therefore, the principles of sis, and psychodynamic therapy. The trauma desensiti-
operant and classical conditioning apply. Operant con- zation therapy merged cognitive restructuring and
ditioning is based on reward and punishment such visual imagery techniques: the patient learns how to
that if a behavior is rewarded, it will increase. Con- relax, then with visual imagery techniques reexperi-
versely, if a behavior is punished, it will decrease. Clas- ences the traumatic event and learns to confront
sical conditioning is based on the belief that behavior is avoided stimuli. Hypnosis was used to assist the patient
brought about by the pairing of events. For example, a in confronting the traumatic event and at the same
man experiences a startle response when he witnesses a time decrease conditioned physiological responses trig-
gunman wearing a red shirt shoot a bank clerk. Now, gered by the trauma. The psychodynamic component
each time he sees a man wearing red, he experiences a was aimed at solving the intrapsychic conflicts that
startle response. resulted from the trauma. There were 112 participants
Systematic desensitization is a type of behavioral in this study, of which 79% were women and 21% were
technique developed to assist patients with avoid- men. Nineteen participants experienced a violent
ance behavior linked to a specific stimulus (e.g., fear crime, 4 were in auto accidents, 83 lost a loved one
of walking alone). A hierarchy of anxiety-provoking from murder/suicide, and 6 patients experienced some
images related to walking alone is constructed in imagi- other type of trauma. Participants were randomly
nation from least to most problematic. Once a level is assigned to one of four conditions: trauma desensitiza-
imagined without anxiety, the person can then move to tion, hypnosis, psychodynamic therapy, or wait-list
the next level of anxiety-provoking situations and/or control. The length of treatment for the trauma desen-
images. sitization, hypnotherapy, and psychodynamic averaged
Frank and colleagues (1988) compared cognitive- 15, 14.4, and 18.9 sessions respectively.
behavioral therapy and systematic desensitization ther- Results showed that symptoms of intrusion and
apy in women contacting a rape crisis center. The study avoidance were lessened considerably in the treatment
differentiated two types of treatment seekers: early- groups but not in the control group. Trauma desensi-
treatment seekers who began treatment within days or tization and hypnosis were found to be significantly
weeks of the assault, and late-treatment seekers who more useful in improving both intrusion and avoid-
began treatment several months post-assault. Partici- ance symptoms compared to the control group; psy-
pants were randomly assigned to one of the two treat- chodynamic therapy was only significantly better at
ment modalities, cognitive-behavioral therapy (CBT) lessening avoidant symptoms compared to the con-

8
Acute Stress Reactions Among Victims of Violence: Assessment and Treatment Gore-Felton

trol group. Therefore, it appears that brief psycho- There have been no empirical studies conducted on this
dynamic therapy is not the best treatment for ame- type of treatment, despite its wide usage. Although
liorating avoidant and intrusion symptoms in cases there is a great deal of anecdotal evidence reporting the
where the trauma is fairly recent, that is, five weeks. effectiveness of PD, it is not clear how effective this
This finding is consistent with Marmar (1991) who treatment is in diminishing PTSD symptoms in the
asserts that brief dynamic psychotherapy has its greatest acute and chronic phases of the disorder.
applicability in cases where PTSD symptoms have
occurred from several months to several years following Psychopharmacology and
a traumatic event. Acute Stress Disorder
Some patients with trauma symptoms require psy-
Critical Incident Stress Debriefing: chotropic medication to reduce symptoms of increased
Many trauma-focused treatments borrow from brief arousal and/or depression. Therefore, a subpopulation
psychodynamic, and cognitive-behavioral intervention of trauma patients who do not respond well to psy-
strategies. When traumatic events such as a random chotherapy may benefit tremendously from treatment
shooting or natural disaster strike, behavioral tech- that incorporates medications targeted at treating anxi-
niques that encourage patients to face their fears ety and/or depressive symptoms. Additionally, clini-
head on and discuss or debrief their experiences are cians need to be aware that there are some patients
often used. Debriefing is believed to minimize feel- who turn to alcohol and/or drugs in an attempt to
ings of anxiety, which will in turn decrease the like- self-medicate and reduce trauma symptoms. This is
lihood that avoidance behaviors will develop, thus, consistent with literature that indicates that individuals
preventing acute and chronic trauma symptoms turn to drugs to manage painful affective states (Roesler
from developing. Many trauma survivors can feel like & Dafler, 1993). Because alcohol has the same chemi-
they are going crazy because of their trauma symptoms. cal properties as anti-anxiety medications which are
These patients often find it helpful to attend a group classified as sedative-hypnotic agents, it decreases feel-
with people who have experienced the same or a similar ings of anxiety in the short-term. However, the addic-
event. The group experience provides an opportu- tive properties of alcohol make it problematic. Patients
nity for patients to share their stories with one who are experiencing trauma symptoms and have
another and receive support as well as validation of alcohol or drug abuse issues should be treated for
their experiences. Patients can provide one another the substance abuse issues before beginning treat-
with a sense that they are not alone. Patients can also ment aimed at trauma symptom reduction. More-
begin to normalize their responses and understand that over, the patient should be evaluated and treated by a
what they are feeling or experiencing is normal and to psychiatrist who is familiar with the psychopharmaco-
be expected. This provides patients with a sense of con- logic management of trauma and addiction disorders.
trol because they can begin to anticipate and under- In summary, psychotherapy along with psychotropic
stand their posttrauma reactions and experiences. An medications is an effective course of treatment for indi-
intervention that incorporates both debriefing and sup- viduals whose trauma symptoms do not abate with psy-
port is Critical Incident Stress Debriefing (CISD). chological treatments or are so severe that the patient’s
CISD was developed in the late 1970s to provide ability to fully benefit from psychological interventions
early interventions in group settings for emergency ser- is impaired.
vice personnel providing education, ventilation, and
support (Freedy, Kilpatrick, & Resnick, 1993). Later Conclusion
this treatment was termed psychological debriefing Individuals commonly experience disruptive psycho-
(PD) and has been used extensively with individuals logical symptoms almost immediately following vio-
directly involved in trauma, such as emergency service lence. Additionally, the research cited provides evidence
workers and providers of psychological aftercare in situ- that many individuals suffer from acutely disabling psy-
ations such as natural disasters (Bisson & Deahl, 1994). chological symptoms consistent with ASD. It is notable

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Volume 10 Lesson 1

that high rates of ASD symptoms occur across many tive-behavioral strategies aimed at alleviating trauma
types of interpersonal violence. These symptoms are symptoms.
important to evaluate (see Appendix 1) because they The initial psychological response to violence can be
cause considerable distress and may indicate risk for severe and may represent acute stress disorder. If the
developing long-term PTSD. However, it is important symptoms are not managed, other psychological prob-
to note that not all victims of violence will suffer from lems may develop, such as posttraumatic stress disorder,
severe psychological difficulties in response to violence. anxiety disorders, depressive disorders, and substance
No treatment strategy has been found to be the abuse. The psychological impairment that results from
most appropriate in treating victims of violence. violence may have a deleterious effect on the lives of
However, a variety of treatment methods have been and victims that impacts their ability to function on per-
continue to be used with survivors of traumatic events sonal, social, and occupational levels. Therefore, it is
in the immediate aftermath of trauma. Most crisis extremely important that the treatment approach
intervention methods have not been subject to empiri- match the symptoms presented. For example, if an
cal study which makes the clinical efficacy of these individual presents with reexperiencing the trauma via
methods unknown. However, the research reviewed nightmares with night awakenings, the therapeutic
comparing different treatment models indicates that strategy may include visual imagery with relaxation
studies that compare control groups with treatment because this approach has shown to be effective at
groups and have good follow-up data tend to use the reducing symptoms of intrusion. A word of caution,
well-established principles of the cognitive-behavioral there is a strong need for systematic empirical evi-
perspective. Moreover, treatment studies, which have dence evaluating the effectiveness of interventions
examined the effectiveness of psychotherapy on post- targeted at ameliorating acute stress reactions
traumatic stress symptoms resulting from traumatic among victims of interpersonal violence. Because of
events, have used imagined and live exposure to trauma this, there is not one particular treatment strategy that
cues. Furthermore, exposure to the traumatic memory can be recommended to reduce acute stress symptoms.
has been shown to be more effective than stress inocula- Therefore, mental health providers should assess the
tion training, supportive counseling, and no-treatment type and severity of acute stress reactions and provide
control. treatment that matches the specific trauma symptoms,
Given the apparent success of therapies that use thereby establishing an appropriate treatment that is
behavioral techniques, it would be wise for clinicians tailored to the patient’s individual needs.
treating trauma patients to become familiar with cogni-

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Acute Stress Reactions Among Victims of Violence: Assessment and Treatment Gore-Felton

Appendix A
ACUTE STRESS DISORDER SCREEN

[Conduct if a person has been exposed to a traumatic event in which the person experienced, witnessed, or was
confronted with actual or threatened death, serious injury, or threat of physical integrity of self or others and the
person responded with intense fear, helplessness or horror. Need to assess at least 48 hours after trauma and not
after 4 weeks.]

I’m going to ask you about some reactions you may have experienced since [the traumatic event]. I’d like for you to
tell me about your experience on a scale from 0 to 4, with “0” being "not at all" and “4” being “all the time.”

Dissociative Symptoms
____ 1. Do you find it difficult to experience pleasure in previously enjoyable activities?
____ 2. Are there periods where you find it difficult to concentrate?
____ 3. Have you ever felt like everything around you was unreal or "dreamlike"?
____ 4. Have you ever felt "numb" or like you couldn’t feel emotion?
____ 5. Do you have difficulty recalling details about [traumatic event]?

Intrusion Symptoms
____ 6. Are there times, even when you don’t want to, that you can’t help thinking about
[traumatic event]?
____ 7. Do you ever experience nightmares related to [traumatic event]?
____ 8. Do you ever feel like you are actually reliving [traumatic event]?
____ 9. Do you feel a great deal of distress when reminded of [traumatic event]?

Avoidance Symptoms
____ 10. Are there places or people you avoid because they remind you of
[traumatic event]?
____ 11. Have you noticed that you have stopped doing certain things because it reminds
you of [traumatic event]?
____ 12. Do you find that you would rather not talk about [traumatic event]?

Hyperarousal Symptoms
____ 13. Do you startle or "jump" more than you did before the traumatic event?
____ 14. Do you have difficulty falling or staying asleep?
____ 15. Have you or anyone else close to you noticed that you have been irritable lately?
____ 16. Do you feel like you have to "get up" and do something all the time?

Impaired Social or Occupational Functioning


____ 17. Are you having any difficulty at work?
____ 18. Do find that you are not as social as you have always been?
____ 19. Are you able to engage in activities the same way you did before
[traumatic event]?

A score of 1 or higher on at least 3 items in dissociative symptoms AND 1 point or higher in each of the other
categories meets the criterion for ASD as long as the symptoms cannot be due to the direct physiological effects of a
substance or general medical condition, are not better accounted for by Brief Psychotic Disorder, and are not an
exacerbation of a preexisting mental disorder (Axis I or Axis II). NOTE: Higher scores reflect higher severity of
symptoms.

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Volume 10 Lesson 1

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