VA Medical Center
Albany, NY
Posttraumatic Stress Disorder:
Attachment Based Experiential
May 16, 2013
Posttraumatic Stress Disorder
Charles R. Kennedy, Ph.D., Gretchen Wilber, Psy.D.
History of Posttraumatic
Stress Disorder
PTSD is an anxiety disorder that can occur after
experiencing or witnessing a traumatic event.
The person experienced, witnessed or was
confronted by an event or events that involved
actual or threatened death or serious injury or
threat to physical integrity of self or others.
The person’s response involved intense fear,
helplessness or horror.
Prediction of Imminent
What is the probability that you will face
a life threatening event upon leaving
today’s presentation?
PTSD Prevalence Rates
Most survivors of trauma return to pre
trauma functioning over time
60.7% of men and 51.2% of women are
exposed to trauma
5% males and 10% of females are
diagnosed with PTSD
Some people have stress reactions that do
not go away or get worse over time.
These individuals may develop PTSD
PTSD Prevalence Rates
Combat exposure is one of the traumas, along
with sexual assault, most commonly associated
with the development of PTSD (Kessler,
Sonnega, Bromet, Hughes & Nelson, 1995).
The estimated lifetime prevalence of PTSD for
the general population is approximately 8%
(Keane, Weathers & Foa, 2000).
It is estimated that 15.2% of male Vietnam
combat veterans currently suffer from PTSD and
the lifetime prevalence for this population is
estimated at 30.9% (Kulka et al., 1990).
PTSD Prevalence Rates
More currently, Hoge et al. (2004) found that 19%
of four surveyed U.S. combat infantry units met
criteria for a diagnosis of combat-related PTSD
following deployment to Iraq.
1.5 million people have served in the Iraq and
Afghanistan Wars. 750,000 have left the military.
Approximately 40% of those 750,000 who have left
the military report mental health symptoms.
At present, approximately 60,000 of the 750,000
who have been discharged are seeking mental
health services at this time.
Military Trauma
Terms used to describe responses to combat
trauma before 1980
Nostalgia (Civil War)
Soldier’s Heart
Shell Shock
Combat Fatigue
War Neurosis
Civilian Trauma
Terms used to describe responses to
civilian trauma before 1980
Railway Spine
Survivor Syndrome
The American Psychiatric Association’s 3rd edition of
the Diagnostic and Statistical Manual used the term
Posttraumatic Stress Disorder for the first time in
PTSD became established as a diagnosis, with the
stressor criterion that people had to have been
exposed to a “recognizable stressor that would
evoke significant symptoms of distress in almost
Recovery from PTSD
o Some veterans experience an immediate onset of
PTSD, symptoms that occur right after the
traumatic experience.
o For other veterans, symptoms begin many years
after they thought they had put their military
experiences behind them.
o Life stressors such as transition to civilian life,
physical illness, birth of a child, divorce, death of a
loved one, or retirement may trigger symptoms
Symptoms of PTSD
Trauma – exposure to a traumatic event that evoked
intense fear, helplessness, horror
Re-experiencing – intrusive recollections, traumatic
dreaming, flashbacks
Avoidance – of others, stimuli connected to trauma
Physiological arousal – exaggerated startle response,
Recurrent, persistent, intrusive thoughts
McCaffrey Study
Nightmares and dreams
Flashbacks and hallucination-like
Gerardi example
Efforts to avoid thoughts and feelings
about the trauma
Avoidance of activities and situations
which stimulate recollection of the
Emotional Avoidance
Psychogenic amnesia
 Diminished interest in usual activities
 Feelings of detachment or
estrangement from others
 Restricted range of affect
 Sense of foreshortened future; loss of
ability to project self in time
Physiological Arousal
Sleep disturbance
Increased irritability, lowered threshold for anger
Impaired concentration
Exaggerated startle response
Physiological reactivity to trauma reminders
Increase in measure of vital signs: breathing,
muscle tension, heart rate and blood pressure
Panic-like symptoms: hyperventilation, fear of
'going crazy' or dying
Evidence Based Practice
Individual Trauma Processing
Prolonged Exposure (Foa et al, 1991)
EMDR (Shapiro, 1989)
Cognitive Processing Therapy (Resick et
al, 2007)
Group Psychotherapy
CPT (Resick et al, 2007)
Seeking Safety (Najavits et al, 1998)
Goal of Treatment
Integration of Thoughts & Feelings
Symptom Reduction
Fulfillment in Living in the Present
Investment in the Future
Goals of PTSD Treatment
Create new memories
Disinhibit imagination
Foster interpersonal connection
Register other than traumatic material
Create a narrative about the trauma, create meaning
Bring the trauma to the present instead of person being
pulled back to the past
Promote chosen action, challenge the fixed action of fight
or flight
Case Example
Mr. L. a veteran with PTSD
Trauma: Motor Vehicle Accident
Jonathan Shay, MD, PhD
Department of Veterans Affairs, Boston MA
From Achilles in Vietnam 1994
“I shall argue throughout this book that healing
from trauma depends upon communalization of the
trauma- being able safely to tell the story to someone
who is listening and who can be trusted to retell it
truthfully to others in the community. So before
analyzing, before classifying, before thinking,
before trying to do anything- we should listen.”
Attachment and Trauma
(Johnson, 2002; McFarlane & van der Kolk, 1996)
“Emotional attachment is probably the
primary protection against feelings of
helplessness and meaninglessness.”
McFarlane and van der Kolk (1996, p. 24)
Towards Attachment-Based TraumaFocused Interventions
Attachment theory is a “theory of
love and its central place in
human life.”
“It is the ability to derive comfort from another
human being that ultimately determines the
aftermath of trauma, not the history of the
trauma itself”.
(van der Kolk, Perry and Herman, 1991)
Interpersonal Traumas are More
Likely to Result in PTSD
(Charuvastra & Cloitre, 2008)
Human beings ascribe meaning to
Individuals who are exposed to humangenerated trauma, such as war, will ascribe
different meanings to their experiences than
will individuals who are exposed to traumas
of a non-personal nature.
The most significant protective and
resilience-recovery variables associated
with combat-related PTSD:
Emotional Sustenance (Schnurr, Lunney & Sengupta, 2004)
Attachment Style (Dieperink et al., 2001; Mikulincer, Horesh, Eilati &
Kotler, 1999)
Social Support (King, King, Fairbank, Keane & Adams, 1998; King, King,
Foy, Keane & Fairbank, 1999)
Attachment Based Interventions in
Trauma Treatment
Emotionally Focused Therapy (Johnson, 1998)
Couples therapy that helps partners reprocess their affective
responses to one another and change their patterns of interaction to
create trust and foster secure attachment.
Family Workshop (VVRP/PTSD Program Albany VA)
Psycho-educational workshop for partners and older children of veterans
with PTSD. Provides family members a supportive, interactive and
experiential opportunity to learn about PTSD and the impact on all family
Strong Bonds (VVRP/PTSD Program Albany VA)
This workshop was developed for the 99th Regional Readiness Command US
Army Reserves, and presented to soldiers and their families throughout the
Experiential Exercise
Intrusive Recollections
‘The Whisperer’
A Letter From Veterans
Dear Brothers and Sisters,
The combat veterans in the Posttraumatic Stress Disorder
Clinic at the Stratton VA Medical Center in Albany, New
York are thinking of you and what you are going through.
Our prayers and hopes go out to you. We hope that you
seek out the help that you may need. We have confidence
that you can go on and live the life you want to live and
achieve your dreams. From our experience, drawing close
to our loved ones is a necessary part of healing. We thank
your family members and loved ones for their
understanding, support and sacrifice. We send them
strength. We salute you.
Your Fellow Veterans