individual response to disaster

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the two could not last for a year; they had to break off. .... of their dying of cancer, have parts of the post traumatic stress disorder at age 71. ... hang many hats on.
INDIVIDUAL RESPONSE TO DISASTER

DEPARTMENT OF PSYCHIATRY F. EDWARD HEBERT SCHOOL OF MEDICINE UNIFORMED SERVICES UNIVERSITY OF TilE HEALTII SCIENCES BETIIESDA, MARYLAND 20814-4799

Published, December 1987

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Additional research support from the Department of Psychiatry and its Chairman Captain Bartholomew T. Hogan at the Bethesda Naval Hospital, Naval Medical Command, National Capital Region, Bethesda, Maryland is gratefully acknowledged.

EDITOR Robert J. Ursano, M.D. Col, USAF, MC, FS

ASSOCIATE EDITOR CarolS. Fullerton, Ph.D.

SECfiON EDITORS

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Marni L. Brooks Shirley Ann Segal, Ph.D.

PRODUCfiON EDITOR M. Susan Dixon

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CONTRIBUTORS

Carol S. Fullerton, Ph.D. Research Associate De:partment of Psychiatry Uruformed Services University of the Health Sciences Bonnie Green, Ph.D. Associate Professor De{Jartment of Psychiatry Uruversity of Cincinnati Jacob Lindy, M.D. Associate Professor De{Jartment of Psychiatry Uruversity of Cincinnati James R. Rundell, M.D. Ca{Jt, USAF, MC Ch1ef Consultation Psychiatry Wilford Hall USAF Medical Center Robert J. Ursano, M.D. Col, USAF, MC, FS Professor De:partment of Psychiatry Uruformed Services University of the Health Sciences

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These Seminars were held as a part of Research sponsored by:

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Human Systems Division Aeromedical/Casualty System Program Office and

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The Chemical Defense Division of the Research and Technology Directorate of the

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Human Systems Division, AFSC Brooks AFB, TX 78235-5000

Other volumes in this series Individual and Group Behavior in Toxic and Contained Environments Performance and Operations in Toxic Environments Exposure to Death, Disasters, and Bodies Groups and Organizations in War, Disasters, and Trauma Training for Psychological and Behavioral Effects of the CBW Environment

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· PREFACE

This is the third in a series of six volumes addressing the psychological and behavioral stressors which can be expected to be part of a chemical and biological warfare (CBW) environment. This volume explores individual responses to disaster through looking at acute and chronic effects of man-made disasters, toxic environments, and the Vietnam POW experience. Through contributions examining the literature and through the examination of new empirical data presented by the researchers, the effects of individual stressors, adaptative responses, and the role of pathological and healthy outcomes to such stressors is examined. Psychiatric treatment and performance issues are central to these questions. In order to better understand the stresses of the chemical and biological warfare environment, it is useful to make inferences from situations where we have data and can better understand the individual and group psychological reactions. The papers in this volume are about such settings. Published literature has explored accidental exposure to organophosphates as well as training exercises in a CBW environment. This data is reviewed to develop recommendations for better understanding the psychological and behavioral responses to CBW. Similarly, the long-term psychological consequences of the Buffalo Creek disaster where an entire town was destroyed through the bursting of a dam can provide us with community and individual response information concerning the effects of disaster trauma on individuals and community functioning. The studies of _psychological responses of Vietnam era veterans and prisoners of war provide the umque opportunity to identify combat stress and its effects. Successful coping strategies for the contained environment of the prisoner of war experience are a part of the findings on prisoners of war. Psychiatric Illness as well as growth, change, and movement towards health are possible outcomes of such traumatic environments. The contributions in this volume look specifically at the responses of individuals to disasters, trauma and combat. Such responses will be an integral part of the CBW environment as it impacts upon all troops and medical care providers. Preparation for this stress and the identification of coping strategies are necessary to prepare for the performance demands and medical care requirements of the chemical and biological warfare environment.

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TABLE OF CONTENTS

"Job's Comforters": Some Conceptual and ................................................. 1 Methodological Problems in Evaluating the Role of Predis.Position Jacob Lmdy, M.D. Long-Term Psychological Consequences .................................................... 39 of Man Made Catastrophes Bonnie Green, Ph.D. Psychological Aspects of Defensive Chemical Warfare: ........................... 71 Two Scenarios, Two Perspectives Arieh Y. Shalev, M.D. Psychological Problems of Prisoners of War: ............................................. 79 The Trauma of a Toxic and Contained Environment Robert J. Ursano, M.D. Col, USAF, MC, FS and James R. Rundell, M.D. Capt, USAF, MC Behavioral and Psychological Responses to Toxic Exposure ................... 113 Carol S. Fullerton, Ph.D. and Robert J. Ursano, M.D. Col, USAF, MC, FS

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"JOB'S COMFORTERS": SOME CONCEPTUAL AND METHODOLOGICAL PROBLEMS IN EVALUATING THE ROLE OF PREDISPOSITION Jacob Lindy, M.D. 29 September 19.87

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Refer to figures at the end of this presentation. COL URSANO: We are Guite informal, and it would be helpful for our group to introduce themselves. Dr. Undy Is Associate Professor of Psychiatry at the University of Cincinnati. He is on the faculty and is Director of Research at the Cincinnati Psychoanalytic Institute as well as Co-Director of the Traumatic Stress Studies Center. He also has a book, Vietnam Case Book, that is being published by Brunner/Mazel. I have discussed with him our overall interest in CBW and the effects of trauma. Everyone here has some interest in that area. Our group will introduce themselves and Dr. Undy will proceed to discuss how "Job's Comforter" relates to traumatic disorders. MS. DAVIDSON: I am a graduate student. I study military stress here at the University. CAPT BARTONE: I am a research psychologist at the Walter Reed Army Institute of Research. I am interested in military occupational stress and have been involved with Bob Ursano's research team looking at the psychological after effects of the Gander military airline crash. DR. SEGAL: I am a research psychologist working with Dr. Ursano. My area of interest is post traumatic stress disorder. CAPT McCAUGHEY: I work in the Military Stress Studies Center in the Department of Military Medicine. I am also interested in stress research. TSGT CERVANTES: I am a mental health research technician, working with Dr. Ursano. I am interested in CBW.

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DR. HOLLOWAY: I am Chairman of the Department of Psychiatry at USUHS and have a long term interest in adaptation to severe environments. CAPT BLAIR: Antarctica.

I am interested in people who go to strange places like

CAPT RUNDELL: I am involved in HIV research. MR. DORAN: I am a psychology technician and work with Dr. Ursano. MS. DIXON: I am a research assistant working with Dr. Ursano. I have been working mainly with the CBW project.

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DR. FULLERTON: I am a research psycholo~st working with Dr. Ursano. My interests are more psychoanalytic and developmental m nature. · DR. SHALEV: I am from the Department of Mental Health in Israel. DR. LINDY: Thank you very much. I have been looking forward to visiting and ever more so after hearing the report from Bonnie Green. She enjoyed your comments about some of our dilemmas in the follow up work with Buffalo Creek. I understand my invitation to come here is really getting to know both the work and the people here and at my institution. An invitation such as this provides me with the opportunity to pull together something that I have been most reluctant to write about. I feel I owe it to the field of psychoanalysis, and to trauma research, to take some of the more social psychological data from various disaster groups and see if there is anything about childhood that we should be attending to. I titled my talk today "Job's Comforters." You may recall Archibald MacLeish's play, "J.B." It was written in the early 1960's. "J.B." is about a modern-day Job cast m a circus type setting. There are two janitors who become Nichols and Zeus, God and the devil. They enact the play of Job in modern day. The part of the play that struck me was the three comforters. In the contemporary 20th century version of the comforters, Job, of course, is the victim, the innocent victrm of absurd catastrophe. He is the survivor whom we are studying, like the Gander families, Buffalo Creek, a supper club fire, and Vietnam veterans. At the height of his misery, he has three contemporary comforters. One is a priest who says "Aha, you have sinned." That, of course, was from the Old Testament. Most of the comforters said that in the original version. The second comforter is a Marxist, and he says, that history is a broad sweep of forces and you cannot understand your suffering, only believe that it is a part of the broad sweep of history. The third comforter is a Freudian, and I will read to you what Hilophas has to say to J.B. and what Bildad says in response. J.B. is responding to these people of wisdom. He is bereaved, in pain, desperate. "You mock me", he says. ''There was a time when men found pity finding each other in the night, misery to walk with misery ... Guilt could be conceived and recognized." "Have we forgotten pity?", he asks of his comforters after their initial comments. The Freudian continues, "No, we have surmounted guilt. It is quite different, is it not? You see the difference? Science knows now that the spirit floats like the chambered Nautilus on the sea that drifts it under skies that drive. Beneath the sea of the subconscious, above the winds that wind the world. Caught between that sky and that sea, self has no will, thus cannot be guilty. The sea drifts, the sky drives, the tiny shining bladder of the soul washes with wind and wave or shudders, shattered between them." So far, the priest comments, "Blasphemy". Bildad says, "Bullshit". My reference is to the ''bullshit". Certainly Archibald MacLeish is no slouch in understanding contemporary thought. But what he has abstracted from Freudian psychology is the notion that somehow we have attempted to explain the complexity of trauma and its psychological aftermath on the basis of an infantile past. The man is suffering and is saying, ''bullshit". It is in that climate that anyone who views childhood as contributing to the contemporary consequences of trauma is making an argument which can be underlined as bullshit. For those of us who work clinically setting with patients, we maintain a clinical notion that is less dichotomous. We are most attentive to the specifics of the traumatic event and to the dynamic situations which are aroused in the mdividual. However, as analysts, we have no other way but to hear the past. The way we hear the past is something that may be worth spending a few minutes on. Dr. Ursano has probably introduced you to that, or at least to the best part of it, but sometimes I feel that psychoanalysts get mto trouble because they generalize from their 2

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individual experiences with a kind of prophetic wisdom which the statistics will not bear out. I feel less that analysts have a right to generalize without the data but more that analysts are terribly impressed by the here and now of transference and the countertransference in patients who have undergone trauma. In other words, in the treatments, the relevant pasts of these individuals come smashing across into the room. It is from this background that we be~ to approach the problem of childhood and post-traumatic stress disorder. Let me illustrate through the various instruments and demonstrate how they correlate with other measures of outcome. Some of us at the Institute were a part of a Vietnam project involving 50 patients which used the same instruments. Later, I will give you more background on those instruments, what the follow-up was like, and what the overall project involved. First, let me tell you about a few people. . I will begin with a man I later named Jeb. Jeb was very striking. He arrived in tom military fatigues, but his military bearing was still present as he entered the room. He was very cautious and sat next to the door, looking about and observing all movement on the horizon through the window behind me. He was non-communicative in our first session except for explaining how he shot up his household. Some of the bullets went about three or four inches above his wife's head and he was frightened. We took small history, learned about his difficulties with alcohol and about his trauma in the war. I ~ave him a packet that contained the self-report instruments we were following. I gave him this at the second interview. He looked at me and calmly ripped up the packet. He said, "I do not want any of your psychoanalytic crap. I do not want to be part of any research. I do not want to be the person to make you famous. Either you are interested in helpin~ me or you're not." After reflectmg on the session, I realized he was right. At that moment, I was the officer in Vietnam who was assigning him risky tasks. I became the person who could risk his life. That is what it would mean for him to become involved in a treatment situation. In the session preceding the one I wish to discuss, Jeb came in quite depressed. He showed more than the angry part of himself. In that more depressed notion, I had been talking about anniversaries and attempting to make some tentative links to Vietnam. He then brought up the anniversary of the death of his infant son who had died of cardiovascular, congenital anomalies, not apparent immediately after birth. He had been exposed to Agent Orange and was experiencing guilt. He believed what happened to him was because of all he did in Vietnam. It was a very agonizing session; and I empathized with him; I had not before. I had felt empathy with his rage but not with his depression. The following session, he entered and told me about his first battle experience and the thrill of his being behind a machine gun. He enjoyed the feel of the trigger, the sense of killing, and the excitement. I felt repugnance. In my unprocessed repugnance, I said something to the effect of, "You know, I have talked to a lot of guys who have come back from Vietnam and they tell me a lot about their experiences and what it is like to arrive. They usually go through a period of numbness and difficulty while adjusting to the climate m Vietnam. But you are telling me the first day you experienced a thrill." I was puzzled, a?d I felt ~ ~ap, something had missed ~y conscio~s thought. I wanted to address a possible transitiOnal phase before he felt this urge to kill. I want to tell you about his next two associations. He was feeling something that he had always imagined he could feel. As he said that, he also said, "You know, I have this memory that is as vivid as can be." It was the memory of sitting at the dinner table with his dad (his dad is a World War II veteran with PTSD and alcoholism). While crackin~ ice in his teeth, his dad slugged him. He was a kid, six or seven years old. That is the p1ece of history. My previous comment of being human before becoming inhuman was a way of slugging him. I stimulated a memory ·related to him and to his traumatic experience. It

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is hard for _me to express the viciousness of this man, and at the same time, describe what developed into a very.solid alliance between the two of us, along with the power of the memory. . : When you ask a man like this what kind of early childhood he had, how could you · get the data m a systematic manner? This is a fellow with an inconsistent alcoholic father who deserted the home frequently. His mother was very cold, distant and unsupportive. He was also severely beaten as a child. What I am trying to introduce in this method is how we got the data we wanted regarding his childhood. What sort of information was it, and what implicit assumptions did we have about this data? We had some assumptions that the soldier who had experienced child abuse was vulnerable to becoming involved in sadistic behavior during warfare and, vulnerable as an adolescent, given the ri~ht circumstances, was vulnerable to carrying out actions that would plague him in his later years. We were making assumptions that these people would be having more difficul~. Did we feel that those early experiences caused the PTSD? Absolutely not. We did feel it was shaping the PTSD in some way. DR. HOLLOWAY: What do you mean by "shaping"? There are two possibilities. It aids in reconditioning where a theoretical construct by progression is required. It is also a catalog, meaning that previous experience is fundamentally what you can order. Which sense do you have in mind, shaping or another sense entirely? DR. LINDY: Let me see. I understand the two aspects you have mentioned. It would shape in terms of shaping the drives. Is that the first idea? DR. HOLLOWAY: That is the third assumption. You have already offered a classification of human and inhuman drives. You have talked about pleasure as being a drive. He took pleasure in killing; therefore, he wanted to kill. You have taken us back into his childhood and cited certain hurtful events. My question really focuses on the word "shape." There is one theory in anthropolo~, which says that culture is fundamentally all of those things that happen mentally m terms of cognitive or physical constructs within a given group. Behavior comes from this catalog. This is a point of view held by some cultural anthropologists. In that sense, "shape" means a catalog. There is another group of people, social anthropologists, who carry out functional analyses where the overall theory has more to do with what they call themselves. Social anthropologists say that there are relationships between people and events, and the way people order themselves in those events, determines the outcome of a functional relationship. This is not something that happens frequently. It would be seen in the simple equation F of X equals Y. A functional relationship; If X changes, Y changes. You have used the word "shape" with regard to previous events. Do you conceptualize previous events as having a functional relationship to present events, and in that sense, F of X equals Y? Or do you see that merely as the accumulation of events and cognitive structure upon which any of us could draw and, therefore, be fundamentally the residual experience that is going to determine things in any case? In other words, I cannot do things that are not a part of my culture right at this moment. I cannot act as if I am a part of a culture in the Kalahari Desert because I do not have ostrich eggs. · DR. LINDY: You have struck on a key word, "shape." In my opinion, those who have used it have not defined it well. Clinically, what I have been thinking while seeing these men is that the combination of symptoms which gives you access to post traumatic stress disorder in the adult is a varied set of presentations. I think it is this man's hostility, alcoholism, and unneutralized aggressive energies that resonate with the traumatic experiences themselves and the early past. I am not familiar enough with the 4

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anthropological formulation to state whether that is a function; however, you may wish to comment later as you hear more. We wanted to examine these questions with the limited amount of data we had available and see if we could shed any light on the situation. One of the major reasons for giving the vignette was not to express what I learned about Jeb's past, but to examine what part of the past the patient spontaneously brings into the situation as the trauma becomes mobilized. I want to also tell r,ou about "Bart." This man had an altercation with the police outside of a bar. His wife had tried to disengage him from the two policemen. He would not disengage and he actually dislocated the shoulder of one of the policemen. I think the reason the charges against him were so tough was that the policeman lost the fight. Bart is a junior executive and works with computers. He is a quite motivated and clearly functions at a high level. He was in the Marines in Vietnam and was pinned down under heavy fire. He has a number of horrendous stories to tell. When remaining underground for long periods of time, he would have sporadic episodes of overt PTSD. Other times, he was a "workaholic" with tremendous drive and energy. Sometimes he would alienate himself from his wife and children. They would fight about it and come back together again. There was a solid sense of this man's underpinnings. As he described to me the nature of his altercation with the police, he heard me and experienced me as an empathic listener. Moreover, he heard me take sides with him against those who did not appreciate what he had been through. This involved a whole series of horror stories in which hyperactive ethics on his part were in violation of underhanded activities taking place at work. Everything spilled out at once. In this instance, he reenacted the experience of being pinned down. He said, "Doc, you are like my dad." His dad was a Basque from Spain. Basques were always in trouble with the Spanish authorities. He grew up on the south side of Philadelphia. You have to know how to handle yourself and cannot always trust the authorities. If you and your dad stick together, you can survive. He told me more early history. Bart was born with a cleft falate, and between birth and age four, he had numerous surgeries. Those surgica procedures and hospitalizations were painful. Often, the doctors did not tell him how difficult it would be. The family ethics were bravery and dad cussing at the doctors. This validated his inner sense of self in the midst of threatening dangerous circumstances. He was a guy with a solid sense of who he was. Traumatized in Vietnam, he had chronic recurrent PTSD . He responded very well in a treatment situation. In ten to twelve visits, he had a major recovery, moved his life around, said thank you and was· on his way. What were our assumptions about this man? Although it was hard to articulate, we felt there were some stressors in early childhood that if responded to properly, could inoculate people from the trauma of war. If the trauma of war was still too much and they were overcome by it, they could develop PTSD. Maybe these people do a better job at getting well. That was Bart. I will present a third case then move to other types of data. This was not my case, and I am not sure that the link to childhood was firmly established on the basis of the patient's own spontaneous associations about the past. We had to make some mferences. In Cincinnati, we are on the edge of Appalachia. Many of the people we see ~rew u~ in f\ppalachia. 'J!ley are country people and are a close family unit. Separation IS a maJor Issue. They will travel doWn to Kentucky for the weekends to see Grandma because everybody in the family does. They will get together around a local bar even if it is in the city. This person is the oldest of four or five boys, very strong and stem. His father is a fair, hard-working farmer who gave his family what they needed. The patient has a 12year-old son whom he feels very attached to. However, he has rage attacks in regard to his son and his inhibition of his rage is giving him somatic symptoms. He has had a 5

workup for an ulcer and he has severe headaches, and somaticises. This was our Appalachian group. We saw them at Buffalo Creek and in a number of areas around Cmcinnati. I liked him and also liked his background. I saw him initially, took some data from him, and a colleague became the therapist. I will focus on one aspect of the treatment. When we met as a study group to go over the cases, the presenting analyst was not a gesticulator. It took a couple of sessions for the group to get a handle on what the unconscious identification was all about. Fairly early in the war, this man had been on a :perimeter. He was a good soldier, had good records, and had many traumatic expenences like other soldiers had. This particular man was in a shoot-to-kill situation on a maneuver; he was at the periphery. A boy, age 12, and a grandfather walked by him. He shot both. The grandfather fell dead, the boy fell fatally wounded. They spent three or four hours between the late night and early dawn. The boy died within his grasp. During psychotherapy, it was discovered that he had a psychotic presence of this boy in his mind. It took form as a head that turned and faced him. The psychiatrist was really shocked. It was possibly a psychotic association or internalization as a way of perpetuating this boy. He could not deal with his death. This was a painful, dangerous treatment in which suicide was very clearly a problem. The treatment was very successful. A boy, his grandfather and the soldier. Our patient, the oldest brother in charge · of the younger brothers, given commission by father to see that things are done right. A leader in the service, he turns to his youn~er brothers, enraged at them. He has to inhibit that ra~e for cultural, moral, and ethical reasons. He turns to his father, enraged at him, inhibited culturally. In war, he has killed both his father and his younger brother. In terms of effect, and in terms of what was stirred in the therapist, he unconsciously named him Abraham. I asked what he was talking about. He was talking about Abraham and Isaac and the dilemma to kill or not kill one's own son. Where are we going to count the traumas here? It is not a negative environment. It is not an environment that is full of traumatic experiences. However, it is an environment where there is tremendous meaning cast on the specific experiences and trauma of war. As we go about categorizing, we have to agree on a healthy early childhood in terms of various indices of that childhood. DR. SEGAL: In the first two cases, you suggested that perhaps some childhood stressors would make one resilient to a stressor in the present. Another person would have a harder time with the present stressor. Are you suggesting that it depends on the individual's predisposition or what role the present or the meaning of the present stressor plaxs? Does the meaning of the present stressor trigger something from the person's childhood? For example, if a person were in Vietnam, he might be able to handle that. If that same person were in Buffalo Creek, he might not be able to handle that because of the meaning it might trigger from his childhood. DR. LINDY: The data is so rich that the way you cut it enables you to see so much. Most of our work has been with Bonnie Green in Buffalo Creek. The connection between the specifics of stressful events and long term psychopathology is very powerful. We presumed we would find a great deal of material on childhood; however, we found very little. We found the experiences of trauma activated in the therapeutic situation. Are we going to rule out the ·Impact of the early past? Maybe we should remain focused on the trauma, its event, meaning, and processmg. We should not forget about the early past. If we listen to it, it may give us leverage, and help in treatment. DR. HOLLOWAY: There is one problem with that. You are speaking of taking notice of the past but have not presented examples of the past.

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DR. LINDY: That is an excellent point. This was underline~ in Buffalo Creek when we wanted to get early memories. When the first person said that his earliest memory was falling in the mud at age 3, we thought it was an accident. But when the 40th person said, "It was when a guy threw a mudball at me," we realized everything was water, swimming, mud and blackness. We were getting a memory triggered by what? Is it the memory that is the cause or vice versa? That point is well taken.

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CAPT RUNDELL: Some believe there is a powerful relationship between the traumatic event and the social and psychopathology. However, a group of p·eople exposed to the same amounts of stress would respond differently. The word -resonate strikes me. It has been my experience that there are combinations of events that happen at one particular point in time, like resonance frequency when driving down the road. It is not the car, the driver or the speed. It is all those events which come together at that particular point in time that cause a supercharged event to occur. Could you expand on that concept? DR. LINDY: I am not sure that I can go beyond your comment. Different disciplines and different ways of looking at things have an "all or none" quality to them. This is true in PTSD when we begin speaking biochemically or talking in terms of psychosocial stressors or predisposition. I was particularly struck by Breslow and Davis's article in the Journal of Nervous and Mental Disorders. One of our major critiques was the need for words like resonate that enable us to see the whole person as having a biological component, predisposition issues, and stressors. When I use the word, I am referring to what happens clinically when I am in the room with a patient; what I feel inside about our interaction, and how that resonates with an event that actually occurred on the battlefield. How, in his grasping for meaning out of that absurd event, he tries to go back to his childhood for some kind of frame of reference. CAPT RUNDELL: And he occasionally finds it? DR. LINDY: Yes, he occasionally finds it. COL URSANO: Were you saying earlier that the patient with PTSD is more prone to experiencing interventions traumatically? From the first case that you conducted, would you make that generalization?

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DR. LINDY: In our experience, the traumatic event is never far from the room. My most dramatic illustration would be the man who kept leaning towards me, and I felt myself leaning towards him in response. I listened for what was coming, and the tension became unbearable. Finally, I said, "Something happened to you in Vietnam when you were leaning this way, and somebody else was learung, toward you." He kept using the phrase, "It is your tum." "You said something about the next person's tum." He finished my sentence as if I was reading his mind. I had no idea where we were but the trauma was very close. He said, "Yes," and his face disappeared. The incident was on the back of a truck when they should have been looking out for enemy snipers. He saw his friend's face disaJ?pear. It was his tum to be lookout. The notion of the trauma being right on top of you 1s true. Let's move to another segment and show the slides. We were involved in three projects with Vietnam following our initial work in Buffalo Creek. We then worked With survivors of fires in Cincinnati and Beverly Hills. The treatment project began in 1982 and 1983; there were 50 cases before it ended. The larger NIMH study began in 1983 and 1984. We did a pilot proJect in 1981. What were 7

we going to ask about childhood? These fellows were not at;IXious and were not the best psychological historians in the world. They reacted to questions about childhood the way Bill did. One of them came back drunk and smashed my receptionist's window after bemg asked this sort of question. I gave him an exit interview and later learned that he was outraged at having his childhood implicated with regard to his trauma. What were we going to ask? We were developing a series of experiences with our patients in the treatment study before we began the NIMH (National Institute of Mental Health) work. We had an opportunity to have some input as to the kinds of questions we would ask. We are trying to look at the experience of the stressor event itself, as well as what things looked like after two or three years and what they looked like after fifteen years. We were also interested in the individual's characteristics. What about pretrauma personality, coping behaviors, defensive styles, and specific meanings of events? How nnght these affect the nature of the post-traumatic cognitive processing, and the nature of the recovery environment and the outcome? We have tried to pay close attention to each of these factors. We explored these four areas: the stressor event, personality predispositions, social supports and post-trauma pathology. With Vietnam, we have a 15-year interval. What are we going to find about personality and l'redisposition? We elected to go with two instruments. One was a childhood trauma mdex and the other an assessment of adolescent friendship. There are 41 different sets of criteria on which someone is to be evaluated in terms of whether or not he or she is likely to successfully complete an analytic process. There are inferences and data gathered with regard to assessments of early function, object constancy, diadic and triadic relationships, character resilience, and childhood trauma index. It told us when childhood stopped. Everything before age eight would be counted; events after age eight would not. We had to draw a line somewhere. What are the specifics? People are not always going to respond to, "How was your childhood?" "Great, doc." The non-directive approach was not going to get us our mformation. We derived a list. The list roughly corresponds to the severe stressor lists for children in the childhood diagnostic piece at the back of DSM-ill. The list is fairly good; although it omits child abuse. You can see the loss of a parent through death, desertion, divorce, or illnesses requiring hospitalization. Extreme deprivation was defined in an operational way. The material was absence of food and shelter, and the emotional was open to the rater. This was a generally sense of abandonment in childhood or severe or repeated traumatization. · We were interested in whether we would find anything with siblings, such as severe psychosis, alcoholism, or disabling accidents. I will not go into all the reasons why we think this is an inadequate measure, but we are convinced it is inadequate. You are receiving information regarding the specific things that could be dated. They were more likely to be reported correctly. We had clinically trained raters who assessed the nature of the home m which the particular set of traumatic experiences occurred. They were asked to rate on a positive or negative scale and were given specific criteria around the availability of an adult to attend to the age-specific needs of the child, and issues of discontinuity. There were three criteria for a positive environment. If you had a positive history, you either marked a plus if it occurred in a positive environment or a minus if it ·occurred in a negative environment. The rater then wrote down how and why they made that determination. We are now working with 200 veterans in the NIMH study. This is from a broad range of current functioning. Many of the critiques of other work regarding childhood and trauma were persistently clinical. This is a non-clinical sample; two-thirds nonclinical, one-third clinical. Many of the people are drawn from industry and are well functioning. One hundred sixty four are white and 36 are black; the average income is 8

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$19,000. There is a wide range in terms of combat experiences and overall psychopathology. CAPT BARTONE: With respect to positive or negative environmental support, was it one general assessment that was made and then applied to any childhood trauma? DR. LINDY: Each trauma was independently assessed, and the rater was asked to give an overall view of the childhood. We then re-examined what we thought were problems. CAPT BARTONE: Are they all based on retrospective reports of the patients? DR. LINDY: Yes. This is a small piece of a large study, therefore, it is not getting a great deal of emphasis. Of the total 200 people, sixty percent reported some kind of traumatic event in childhood, and forty percent are free of trauma. CAPT RUNDELL: Was there a control group of non-PTSD people?

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DR. LINDY: No, there should have been. The frequency of these different groupings of childhood traumas was somewhat interesting. Over one quarter of the total sample lost a parent through death, desertion or divorce within the first seven years. An additional 3.5 percent lost a parent surrogate. Approximately a quarter of the veterans lived their earliest years in the presence of an alcoholic parent. One-eighth experienced a serious illness of a parent or sibling that required hospitalization. That includes some of the psychotic parents as well. One-eighth were living under conditions of severe depravation. We thought some of these individual traumas would be connected with certain issues that we would be looking at later. We were not able to predict very well, but there were some interesting findings. A difficult problem for us here is if you ask people what trauma they experienced in their first seven years, you may find out what you don't want to know. You may discover that, by being black, they were ~ore likely to be in larger families and have less education. They were also more likely to have had some kind of psychiatric diagnosis prior to service. At Buffalo Creek, we asked standard questions about the nature of the stressor experience. We broke the stressor experience down into seven different factors. Most significant was the general combat factor and a second factor we called special assignments. These were people who were tunnel rats, were on long range reconnaissance, were demolition experts or were medics. At first, we thought this was a rather peculiar array of roles. The roles had in common their dangerous nature and the notion of being a protector of lives. Mistakes in those roles were more likely to be felt by the person experiencing them, possibly because of the deaths and other military catastrophes. Those with more childhood trauma were more likely to be in special assignments. They were more likely to frequently experience combat situations that threatened their lives. On an inverse level, the less your childhood trauma, the more likely you were to be in the artillery or a safer situation. COL URSANO: How was the information on childhood trauma obtained? What · kind of inquiries were made to elicit the history of childhood trauma? DR. LINDY: Essentially from our check list. The rater said, ''Tell me about your family when you turned eight." "Who was in the home?" There is a demographic chart of who was in the home. "I want to ask you some questions about events that may have occurred in your family up to that time." The rater went through the list one question at 9

a time. The positive history came from askin~ what the trauma was like for that person and how people in the family helped. The ratings were done on that basis. COL URSANO: Were these raters psychiatrists? DR. LINDY: These were research assistants, who were psychologists with some

clinical training. It was not the world's best instrument. COL URSANO: You are making important comments on the role of childhood trauma in career selection. This information should be available from other sources. Perhaps in terms of whether to ask or not how many have experienced death of a parent. To look specifically at whether or not that shows up in different career choices in the military is an interesting question. The biggest confounding factor is that those that have lower education, tend to be single and black and end up in those areas. Are those demographic variables controlled for? DR. LINDY: Not yet. We will be presenting the race differences in the meetings in Baltimore. We have some black-white issues that look like high childhood trauma and low childhood trauma differences. Whether or not that is going to be a different ratio is not completely clear.

COL URSANO: The factors you are interested in are also indicators of socioeconomic status. Socio-economic status tends to dictate those choices and education. DR. LINDY: Correct.

COL URSANO: Particularly in Vietnam.

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DR. LINDY: This instrument seems to be telling us that the people who respond with the history of the childhood trauma are more likely to be m these special assignments, undergo dangers in combat and are less likely to be in the artillery.

COL URSANO: How did you understand the larger family? What was that comparison? Was that aT-test? Is there a cut-off in terms of size of family? I saw size of family related to degree of trauma. Did you construe that as being related to socioeconomic status? DR. LINDY: Psychologically we thought there were more things to happen, and more people for things to happen to. However, most of the traumas are to mother or father rather than to siblin~s. Maybe mothers and fathers are more likely to be alcoholics in larger size families.

COL URSANO: Thinking of your measure of deprivation, available material resources would be spread out over more people in a larger family. DR. LINDY: That may be.

COL URSANO: Some of the other items you collected data on also operate on small groups. The question regarding to what extent family size relates to an ability to operate in small groups could be an important question, for example, peer relations. We have been particularly interested in small groups. DR. LINDY: I realize this, and before I fmished, I wanted to make sure we mentioned the issue of adolescent friendship as related to ·our studies. 10

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We tried to ask whether the high childhood trauma group would have more general pathology 15 years later? The answer to that is yes. CAPT RUNDELL: Trauma-related pathologies? DR. LINDY: No. Non-trauma-related pathology. We did complete the lifetime SADS, on every person. We had a chance to look at those diagnoses which were not PTSD and those that were. H you look at anxiety and depression and their overlap with PTSD, which are you picking up? It was largely in the anxiety group, but it was also in all other areas. Anxiety and depression met statistical significance as did other diagnoses. One of the mteresting aspects of the childhood trauma, with regard to current anxiety and depression, is that the differential between positive and negative environment distinguished the depressives. The negative environment was predicting depression, whereas numbers of childhood traumas were predicting anxiety diagnosis, general anxiety disorder, panic disorder and phobic disorders. So the first set of questions is, is there anything in this instrument, or what else is it tapping into that is predicting general pathology? CAPT BARTONE: Did you have many cases where childhood trauma consistently occurred in a positive environment? It would be very interesting to see the negative findings. DR. LINDY: We will try to look at that. COL URSANO: The zero plus and minus on your slide? DR. LINDY: The zero group is no childhood trauma; that is 40 percent of the sample. The plus is the person you are looking for. That is the person who has had traumas in childhood, but in a positive environment. CAPT BARTONE: Overall, or just on average plus or consistent? DR. LINDY: Overall. The raters tended to rate uniformly. There were six cases that were mixed. The mixed ones looked like the negative ones. We made a series of five or six different groupings, but the ones that made the most sense were no trauma, positive environment, negative environment. CAPT BARTONE: hypothesis, do they not?

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Those findings tend to argue against your inoculation

DR. LINDY: So far, the variety of outcome measures we were using included the psychiatric evaluation form; a mental status examination with 19 dimensions of psychopathology looking at impairment levels. The OVS is the overall severity level. It is on a one to six basis. By putting the asterisk to the left, the point of significance is a correlation between that score and a running count of numbers of traumas in childhood. You are familiar with the symptom checklist. Symptom distress and global severity index on a zero to four scale also correlates with numbers of childhood trauma. A continuous measure of pathology also seems to be connected with the incidence of childhood trauma. The PDQ is a separate topic that I am omitting; we will be talking about it in Montreal. We can get back to your question about the inoculation. Lifetime history of PTSD is the best single thing to look at. The no childhood trauma group shows 35 percent, the positive group shows 52 percent and the negative shows 43 percent. 11

COL URSANO: Does this include Vietnam-related PTSD? DR. LINDY: This is only Vietnam-related PTSD. The zero group is significantly less than the plus or minus groups. The other numbers are not significantly different. We thought we were getting more PTSD with childhood trauma than without it. If PTSD is what we think it is- trauma-specific-- that is the major ideologic factor. If we controlled for combat stress, we indicated that by the asterisks. The parenthesis mean it is still significant after we controlled for combat stress. We thought the ·clearest measure would be intrusion and avoidance. It is hard to find things that are good single measures of the nature of the illness. Avoidance is significant. When you correct for combat stress, you lose the significance. In terms of childhood trauma, the argument would be that PTSD is an external stressor. If you take that out of your statistical position, you lose the predictive capacity of childhood. Why would some of our subscales that are so highly correlated with PTSD correlate with childhood trauma and not lose their significance when we corrected for combat stress? We also had a continuous measure for PTSD and it did not correlate with childhood trauma. I think we have a mixed bag in regards to whether childhood trauma is predicting PTSD, and if so, is that corrected when we take out combat? We now come back to the positive people, and are working with those who had PTSD. There were 88 out of 200. Twenty-seven became better within three to five years before we evaluated them. They stopped having symptoms of PTSD and were having none when we interviewed them. Here was a subsample that we came upon that had spontaneously recovered from PTSD. What do they look like in terms of childhood trauma? What was the likelihood in each of the different groupings to fall into the recovery category?

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COL URSANO: What was the time from symptom onset to recovery? DR. LINDY: Most of these people had the dia~nosis within the three to five years that followed Vietnam. There was a clearly identifiable diagnosis within the three to five years preceding the interview. The diagnosis was not present at the interview. In terms of childhood trauma, the capacity to recover is highest in the inoculated class. Those with childhood traumas in the positive environment category seem to be the best spontaneous recoverers. This relates back to Bart, and the likelihood of recovery. Only two of twelve people in the negative group recovered. CAPT RUNDELL: The 200 includes these people plus who else?

COL URSANO: Only the groups that have a diagnosis of PTSD. CAPT RUNDELL: And who are the other 120? DR. LINDY: They are combat veterans who have never had post traumatic stress disorder. CAPT RUNDELL: How were they selected? .

DR. LINDY: Everyone in the sample has been in Vietnam and in combat. By design, two-thirds are currently functioning well. We are drawing them out of industry. They have a 17 percent PTSD rate whether or not they are functioning that way. We are gettmg the other groups from Vet centers, disabled American veterans and from various VA facilities.

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CAPT RUNDELL: How is the plus or minus determined? Is someone assigned to the plus or minus group? DR. LINDY: Zero is no trauma.- With the plus or minus group, there is trauma present. The plus means the trauma is in the positive environment and the minus means the trauma is m the negative environment. CAPT RUNDELL: How is the environment assigned?

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DR. LINDY: On the basis of the judgment of the rater with regard to the degree to which the trauma was addressed emotionally. Was it addressed healthfully in the family? Was there constancy for the child in question? Was there some energy available in that system for adult attention to the phase appropriate needs of the child. It is rated in terms of how they responded as an organism, how they responded and related to the stress, and how they attended to the needs of the child. CAPT RUNDELL: Did you try to gather that information with a specific set of

questions?

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DR. LINDY: Once we identified the specific trauma, we asked an open ended question, such as "How was that for you; how did people in your family respond to that stress?" The rater made a rating on the basis of what they said.

COL URSANO: Was the rater the same as the interviewer?

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DR. LINDY: Yes. DR. SHALEV: Is the data regarding PTSD recovery based on the retrospective lifetime questionnaire? DR. LINDY: No. The PTSD was done like the other diagnoses. The symptoms were gathered and the diagnosis was made piece by piece: When did it first start? What is its history? It follows the flow chart as with a SADS, a SCID or a DIS. DR. SHALEV: When did it stop? DR. LINDY: That was routinely asked for all the disorders. It was not something we were actively looking for.

COL URSANO: Does a version of the SADS have a PTSD module? DR. LINDY: No, we had to write it. Since childhood trauma was such a little piece of the pre-morbid past, and since we had as many questions as we did about it, we thought it would be useful to pull out two groups where there could be no question. We took the people with the negative childhood pasts and added to them people who had a psychiatnc dmgnosis before service and added to them people with unquestionably poor adolescent friendships. We took another group where there was no trauma, adolescent friendships were high and there was no preVIous diagnosis. We really got confused; therefore, I must go back and give you some background. With the adolescent friendships, you may or may not be aware that in the SADS there is a section where one assesses their adolescent relationshifs and friends. You are looking at three dimensions: the quality o the relationships, the initiative put forth (passive versus active), and you are attempting not to look at popularity. However, you do look at popularity by examining the number and the

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quality of friendships. Specifically, where one stood in those friendships. To get a positive score on adolescent friendship on a one to six scale, you have somebody who is popular, makes friends easily, and who shows some capacity for leadership. When we did our splits we put them in the top group.. In the bottom group you have people who are isolated, who make friends poorly, tend to be scapegoated and are outcasts in their peer group. That group correlated in terms of childhood trauma. That latter group was the extreme deprivation group. There was a very high correlation between that and the poor adolescence group. There was almost no crossover between childhood trauma and adolescent friendship. None of the groups predicted an increased number of traumas, e.g., the loss of a parent or alcoholism. There is a negative correlation with regard to the lifetime diagnosis of PTSD. The better your adolescent friendships, the more likely you are to develop PTSD~ That is true with combat and with protective and dangerous missions. We are stumbling on something that we assumed would be acting as a resilience factor. This same group was the most resilient once it had the disorder. The recovery rate is very high in those with good adolescent friendships. They use social supports well, both before and after. When we tried to put the three issues of previous diagnosis together to make an all good, all bad grouping, we learned that the correlations inverted with regard to adolescent friendship. Bob Lauffer and Elizabeth Brett have some findings in this area. They developed the notion of the disillusionment of the adolescent leader who was a volunteer in Vietnam. He became involved, got in over his head and was devastated by the emotional impact of his experiences. We have a lot of anecdotal material about that kind of patient. I could give you two or three clinical examples. CAPT RUNDELL: Does adolescent friendship predict anything else? DR. LINDY: General pathology is not significant. Other diagnoses in adulthood are also not significant. In terms of PTSD current, it is not significant. They tend to use avoidance less than other groups. CAPT RUNDELL: Would the same factors that make someone not have good quality adolescent friendships also make them less likely to give an accurate childhood trauma history? DR. LINDY: I think so. CAPT RUNDELL: Could it change the correlation? DR. LINDY: Yes, it may to some extent. There are some funny answers to childhood trauma in those who meet any of the social diagnostic categories. We would have to review adolescent friendshiJ?S separately. At the moment, we are looking primarily at childhood trauma. Bonrue Green and Marian Culdean Glaser do seem to be convmced it is a real finding. It is very similar to a group that Bob Lauffer and Elizabeth Brett found in their data from the legacy study. In certain kinds of trauma, Vietnam being one, factors which would lead to loyalty and leadership may make a better soldier and a better recoverer, but they may also increase risk. They can also increase the traumatic de-idealization as a component in this particular post-traumatic stress disorder. COL URSANO: Those with better adolescent friendships showed an increased probability of a lifetime diagnosis of PTSD? DR. LINDY: Correct.

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COL URSANO: To what extent does the trauma represent the stressor, and to what extent is the loss of social supports? One could make a case that those individuals who had better adolescent friendships might also be more prone to want certain friendship patterns and to experience the disruption of friendship patterns as disturbed. Therefore, the alterations in the social supports that occur, either in combat or after combat, are the experience that disrupted their life patterns.

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CAPT BARTONE: We had a group of our survivor assistance officers who helped bereaved families following the Gander crash that might fit that description. We found that social support, as we were measuring it, was a commitment to the environment~ lending resilience or resistance to the negative health consequences of that kind of stress. There was one anomalous group of fellows who were both low in social support and low in personality hardiness who did not seem to suffer. We speculated that those may be soldiers who were less engaged in a social network and thus were less likely to be distilled by social stressors. CAPT RUNDELL: The POW studies showed that the groups presenting schizoid type responses or adaptations did better than some of the other groups. DR. LINDY: How long afterwards was this study done? CAPT RUNDELL: I do not know. DR. LINDY: Many years later or shortly after? CAPT RUNDELL: One to five years. COL URSANO: All were within six months of return from Vietnam. DR. LINDY: Maybe I can conclude. COL URSANO: The finding points out the strengths of adolescent friendships and propensity of PTSD. DR. HOLLOWAY: That R was .13? ·

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COL URSANO: It was quite small, but significant. DR. LINDY: I am not clear why the numbers are as small as they are. I will have to go back to our file cards and find out which treatment cases are not being reported currently. We were interested in terms of recovery and whether some of these patterns would repeat themselves if we looked at treatment groups. We divided the treatment groups into two parts. One in which the doctor and patients were able to establish a dyad that was successful for a year, and where they were able to engage the trauma. This does not count the interruption group. They were never in treatment. There was not a category for them. Then there were therapies where the trauma was engaged but the two could not last for a year; they had to break off. The no childhood trauma group is more likely to be able to develop a relationship that sustains itself during a treatment process. We did not see much difference in terms of a positive or negative environment. We had thought the positive environment people would be those who were able to stick it out. The numbers are very small.

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DR. FULLERTON: · Did you have any data as to whether these people had prior

psychiatric treatment? DR. LINDY: Those questions were asked. For example, working backwards from the SADS: did you have it, do you have it now, did you ever have it, did you have it then before you went to Vietnam? We could infer the last question by a~e. The most important line is on the bottom· of this slide. If there was any diagnosis pnor to service, the correlations with PTSD are very high. DR. FULLERTON: This is diagnosis, not a conclusion as to whether or not they

were actually treated? DR. LINDY: You are asking a treatment question? I do not think we would have that data on the treatment cases. Treatment cases did not get a SADS; we only have what the therapist put in the record. The therapists were asked a set of questions that may be relevant to that. For example, "Having treated this man, how much of the pathology would you assess was related to pre-morbid and how much would you assess was related to combat and its aftermath?" That was 70 percent combat and aftermath, 30 percent pre-morbid.

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DR. HOLLOWAY: How was combat measured? DR. LINDY: There were seven factors that we looked at in working with a series of the Wilson-Krause combat role and combat stressor groups. There were seven groups that factored out. DR. HOLLOWAY: That is where you started? DR. LINDY: Yes, and then these are corrected for combat factor one which tended to intercorrelate with the other ones. COL URSANO: Those are not high correlations. DR. LINDY: Absolutely not. That is my tentative summary. Childhood trauma should not be ignored as a contributor to current psychopathology, both in terms of its contribution to overall psychopathology, and to some extent, PTSD specific psychopathology. Correlations are at a lower level. The impressiveness of the relationship of stressor event itself is at a much higher level than childhood trauma. The group that has had no trauma at all seems less likely to be in dangerous situations. In terms of role, they are less likely to have reported the frequency of danger to themselves, and less likely to have developed PTSD than the other categories. Our positive group (childhood with trauma in a positive environment), tends to have had more combat and they sought or were assigned to special missions. They had more overall combat stressors, more PTSD and were the most resilient in terms of spontaneous recovery. COL URSANO: You commented about it being one of the most interesting findings. I agree with you. The recovered area, the zero plus and minus at the top, looking at childhood trauma, present or absent, plus or minus being whether or not the childhood trauma occurred in a supportive family environment prior to age eight or nonsupportive family environment. The PTSD occurred more often in those with childhood trauma, but recovery was more rapid in those with a positive family environment. DR. HOLLOWAY: Did you control for social class?

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DR. LINDY: We know that there is a confounding variable with race, and we . suspect that we are picking up social class confounding variables. DR. HOLLOWAY: We started out with one of the comforters of Job who was a Marxist. He might say that if you are poor, you are more likely to be exposed to dramatic variables in society. What you are seeing here is the resilient poor. COL URSANO: Yes, but if you look within the group that had trauma, those that are in a sup_{>ortive environment with trauma have recovered. This sounds similar to questions rrused regarding the role of personality disorders in Vietnam and their relationship to rate of recovery.

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DR. HOLLOWAY: They were exposed to more of that in Vietnam. Belenky's early claim was that if people had an excessive schizoid personality, recovery was poor. The problem was not recurrence, but rather recovery was poor. Did that data disappear in the war? DR. SHALEV: They were not excessive schizoids. DR. HOLLOWAY: What about people who talk about words a lot and do not associate well with people? Is that preferential data or not? DR. SHALEV: No, it is not. DR. LINDY: My last sentence is about the people in the negative group. Generally, those who experienced childhood in a negative environment tended to be involved in more intense combat and special mission operations. Their exposure to the grotesque is greater as well. They score higher on the hurting and killing aspects of the combat stressors compared to the plus group. They are less likely to develop PTSD during their lifetime but their spontaneous recovery rate is by far the lowest. DR. HOLLOWAY: There are several confounders here. DR. LINDY: We do not know what recovery is. Recovery is operationally defmed in our study which is done 15 years after combat. You take a careful history of a diagnostic entity; you move back with it through time and produce a chart which says, retrospectively, "I had the symptom between two and five years after, and in the past two to five years I have not had it". One can quibble over whether that is recovery; that is what we mean by the phrase. DR. HOLLOWAY: If, for example, I am taking care of four-star generals who have been asymptomatic since the time of their original problem and who, in the context of their dying of cancer, have parts of the post traumatic stress disorder at age 71. They would be recovered in your chart. How about a word like remission? DR. LINDY: Remission is a good word. DR. HOLLOWAY: We do not know whether they are recovered or not because they are exposed to repeated traumas. A person who has severe symptomatology right now might have a tendency to cite things with a particular fear or horror as opposed to those who are trained in the current sense. Thus, is it the same as discussing memory and event. I am struck by how one person can go to pieces much like another, but if you ask them about the experience, it can be felt somewhat differently depending on the 17

circumstances of the asking. When I talk to many of the men who were in Vietnam and hear about the special missions, I find that these missions are ·sometimes quite unusual. I can understand their report, empathize with it, but it is a memory. Tins is valuable data about the way in which we might recognize and develop a metaphoric discourse about the past. DR. LINDY: That is psychotherapy. DR. HOLLOWAY: A lot of discourse is.

Just for dialectic, the point is that shifts in that view can be tremendously important. DR. LINDY:

DR. HOLLOWAY: If the Phoenix Program . were as big as it sometimes ~s purported to have been, it probably would have been carried out by about two million soldiers who were marchin~ out of Vietnam carrying out the people's program. If all of the units I have now interviewed, including Vietnam veterans, were all destroyed, then I would have a little trouble with knowing why it was only three platoon level units· which were, in fact, destroyed during ten years of war. There are lots of things like that that I think deserve some attention. If you also do another kind of interview with those folks, frequently for them, the unit was destroyed. COL URSANO: Harry, your argument would be that one should frame the question as the role of metaphor, memory and recall. DR. HOLLOWAY: Symbolic organization is very important, and it is heavily modified by very stressful events. The problem is, if you try to get that funded through Congress, It is not nearly as fundable as a bad experience had by a real person with a real history. Thus, the use of that language in that particular marketplace discourages the use of that particular formulation. One should appropriate money for people suffering from metaphors. Wrong. We may have some metaphors that said we suffered, but every one of those things is a part of the discourse and thus, the problem. DR. LINDY: I am curious about your response to the way in which the data I've presented seems to be ordered. Does it seem to make any sense to you? Let's put into abeyance our multiple questions about method and look at some of the findings. Does it add up? DR. HOLLOWAY: Let me ask you a question and turn it around. What study do you derive from your data that you want to do next? DR. LINDY: We are at a point of discussin~ the publication of this data. I do not have any doubt that we could get it published, but Is there something here to be said? If the answer is yes, then maybe we could go to the next study.

COL URSANO: This raises the question of the broad catalog with which one should approach trauma. It certainly is not evident in analytic literature and probably not in psychiatric literature. You are trying to make the point about broadening the way in which people think about the role of trauma and predis?osition as well as the fare of subsequent pathology. To what extent does your empincal data support that view? Your findings around recovery or remission are provocative but not ones that I would hang many hats on. The biggest dilemma is the compounding with SES. DR. LINDY: We can answer those questions. 18

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DR. HOLLOWAY: Why would you not publish? DR. LINDY: There is a point in a study where you are in it for certain reasons. You are immersed in it and not sure what you have. You then pull out of it and say, ''This is what we have and it is well worth adding." The reason for not publishing is the possibility of a confounding variable. We may not be saying something independently about childhood trauma. A second reason would be indecisiveness. One could not leave the investigator interested in one direction. We were just too marginal. DR. HOLLOWAY: Let me go back to my previous question. If this data suggested further studies, it seems to me it would justify publishing them. If they do not suggest further studies, then it seems to me you would wonder about publishing them. There is an inherent limit within the data set that asks if it is open to discourse or not. What are your thoughts about this? Do you think it suggests other work that needs to be done? There are some very good studies published about it that are suggesting someone do something. I wonder if we could get caught up in the obsessiveness of just focusing on the purity of variables and miss the overall importance of the study. If the research raises a set of questions that initiate discussions, then it would be worth publishing. If it did not, then you might wonder whether it is worth the effort. DR. LINDY: Yes. DR. SEGAL: How does the trauma positive environment group and the trauma negative environment group compare on additional diagnoses? DR. LINDY: I am trying to think if we have divided those questions that way. We know that the more trauma, the more the additional diagnoses. We know that in the positive environment, they move towards anxiety type diagnoses. In the negative environment, they move more toward depressive diagnoses. DR. SEGAL: Are those ~roups purely PTSD in both cases, or is one more anxiety and the other depressive disorders? DR. LINDY: Those would be questions about non-PTSD diagnoses. In your negative environment you have a higher tendency to pick up dysthymics and major depressions; in your positive environment you are more likely to pick up anxiety states. DR. SEGAL: I am wondering if that clouds the findings because you are talking about the extent to which the childhood trauma effects PTSD. However, it sounds like you do not have purely PTSD in childhood. The role of the childhood trauma determines an additional diagnosis. DR. LINDY: Would it be nicer to have a group that simply did not have all these concurrent diagnoses? Absolutely, it would have been better to have asked this question in another sample that was more acute, for example, the hostage situations, or the Beverly Hills fire. · COL URSANO: Would you see the issues around recovery or inoculation as affecting your psychotherapeutic group? DR. LINDY: As I resonate with Dr. Holloway's comments about where do I go, I go back to my patient. My colleagues go back to the next study, but I go b~ck to my patient, and hopefully, we reconnect around our next study. How do I approach a 19

patient? Would this help me in .terms